Histamine at high dilution reduces spectral density in delta band in sleeping rats

Homeopathy (2005) 94, 86–91 r 2005 The Faculty of Homeopathydoi:10.1016/j.homp.2004.10.002, available online at http://www.sciencedirect.com ORIGINAL PAPER Histamine at high dilution reduces spectral density in delta band in sleeping rats G Ruiz-Vega1,􏰍, B Poitevin2 and L Pe ́ rez-Ordaz1 1Laboratorio de Biofı ́sica, Instituto de Fı ́sica y Matema ́ticas, Universidad Michoacana de San Nicola ́s de Hidalgo, Morelia, Michoaca ́n, Me ́xico 2Association Franc-aise por la Recherche en Homeopathie Histamine is a central neurotransmitter, it increases arousal via H1 receptors. This study examines the effect of ultra-diluted histamine on arousal through changes in the sleep pattern of Wistar rats. The spectral density in delta (0.5–2.5 Hz) band, one of the three major spectral components of the sleep-electroencephalogram, was analyzed against time. Rats were randomized to receive histamine 30c (histamine 30c, 0.05ml every 20min during the first 2h orally), histamine intraperitoneal pre-treatment/histamine 30c (histamine 6 mg/kg i.p., followed by histamine 30c) or solvent control. The mean delta band spectral density was lower in the histamine 30c and histamine pretreat- ment/histamine 30c groups than the control group. Significant differences between histamine 30c and baseline during the first 2 h imply an immediate effect. These results also suggest a dynamic process in which the system spontaneously evolves between two locally stationary states according to a power law. From the time perspective, the system approaches, asymptotically, an equifinal state. Homeopathy (2005) 94, 86–91. Keywords: histamine; ultra-diluted; homeostatic; self-response; sleep pattern; homeopathy increase wakefulness and decrease slow wave sleep; while H3 receptors play an active part in these mechanisms by regulating histamine release.11,12 As a highly diluted stimulus applied during the sleep cycle of healthy subjects, histamine would be expected to increase arousal, according to the similia principle; which in turn promoting a homeostatic host response. Sleep loss, either pharmacological or mechanical, provokes a counteraction, called ‘sleep homeostasis’, which involves an increase in non-REM sleep intensity. The main marker of the intensity of non-REM sleep is EEG slow-wave activity, defined as the spectral density in delta band, which normally declines in the course of sleep time and increases in the sleep deprivation.13 In this study, we evaluated sleep intensity as the spectral density in 0.5–2.5Hz band, calculated over the completenoise-freefile.Thisassumptionreliesonthe fact that this domain constitutes the main frequency of non-REM sleep.14 It exceeds those of waking and rapid-eye-movement (REM) sleep by an order of magnitude,15 and closely correlates to slow wave non-REM activity. This marker has been described in previouspapers.16–18 We assessed the effect ultra-low-dose (ULD) hista- mine on arousal using this parameter. In addition, as the effect of the combination of pharmacological and ultra-low-dose of the same compound has been formerly reported previously,18–20 we also investigated the combination of pharmacological+ULD histamine. Materials and methods Animals Young adult male Wistar rats weighing between 250 and 350 g ðn 1⁄4 36Þ; were used. All procedures complied withMexicanFederalRegulationsfortheUseandCare of Laboratory Animals (NOM-062-ZOO-1999). Rats were feed ad libitum on standard diet (Purina, Mexico) and randomized in three groups treated as follows: 􏰐 Solvent (orally), 􏰐 Histamine 30c (orally), 􏰐 Histamine pre-treatment/Histamine 30c: histamine intraperitoneally (6 mg/kg i.p.) followed by histamine 30c orally. The oral dosage was 0.05 ml each 20 min during the first 2h. Pre-treatment was one i.p. injection of histamine (histamine dihydrochloride) in double dis- tilled water. Rats were anaesthetized (40mg/kg pentobarbital), three 1.5mm diameter stainless-steel electrodes (resis- tanceo0.1 O) were implanted in the animals’ cranium after trepanation with a hand-held Foredom drill, securedwithdentalresinandconnectedtoa15A54 Grassmultichannelamplifier(Astro-Med,Inc.West Warwick, RI, USA). A bipolar EEG was recorded through two of these electrodes, which were implanted bilaterally in the parietal region, and the third one in ARTICLE IN PRESS Biological effect of highly diluted histamine G Ruiz-Vega et al the frontal area for reference (ground). Trepanation points were spotted stereotaxically at the following coordinates: 3.8 mm posterior to Bregma and 4.5 mm lateral to the side of central line for the bilateral electrodes.21 After surgery the animals were allowed to recover for 6 days; a further 1-day habituation period took place, in which the electrodes were connected to the signal amplifier by a cable that allowed freedom of movement. During the pre-operation and recovery periods, rats were maintained under a steady light–- dark cycle. Next day baseline was recorded without any mechanical or pharmacological disturbance. The next day treatment measurements started. Sleep deprivation could be the consequence of pharmacological or mechanical stimuli (the repetitive sleepdisturbancefororaltreatmenteach20minduring 2 h); or superimposed effect of both. Hence, in order to estimate objectively the possible effect of the highly diluted histamine in histamine pre-treatment/ hista- mine30cgroupparalleltestswerecarriedoutwithtwo additional groups (12 animals per group): Histamine i.p.(6mg/kg,i.p.)andsaline,withnosleepdisturbance due to repetitive oral administration. These were supplementary ‘positive controls’. Materials Histamine hydrochloride was obtained from Sigma Chemical Co. (St Louis, MO, USA). Saline solution (0.9% NaCl) was obtained from PiSA, Laboratorios Mexicanos. Ultra-high diluted histamine and the solvent (87% alcohol/water) were acquired from Laboratorios Medicor (Mexico). Preparation of the histamine 30c involved 30 successive centesimal dilu- tions (1/99 vol%). The final concentration is theoreti- cally equivalent to 0.9 􏰑 10􏰏61 M. Experimental set-up Rats were housed individually in wooden cages built to avoid external disturbances but allowing observa- tion. Daylight was provided so as not to alter the circadianhistaminepattern.22Eachsubjectwascon- nected to a 15A54 Grass amplifier module, its controls set as follows: sensitivity 20.0mV/div, display gain 1, band-pass filter 0.3–30Hz, line filter on. The output wassampledat8Hzandonlinedigitizedwitha National Instruments AT-MIO-64E-3 card and Poly- Views v 2. software (Astro-Med). Output was stored in a computer for mathematical analysis. Sampling frequency was chosen taking into account delta band features14 as well as the Nyquist theorem.23 Experimental procedure Six rats were tested at a time, one to a cage, two for eachgroup(fortechnicalreasons,1sessionwasrun withonly5subjects).Measurementsstartedtheday after baseline recording . At this time rats were fed their regular diet and purified water ad libitum. At 10.00, t 1⁄4 0 (t, time in hours), rats from histamine 87 Homeopathy 88 Biological effect of highly diluted histamine G Ruiz-Vega et al pre-treatment/ histamine 30c group received a single dose of histamine i.p., simultaneously oral treatment was initiated for all three groups. On the completion of 8h recording session, the tests concluded for the six subjects and the process was repeated with six new ones until all were tested. Mathematical analysis of datawascarriedout‘blind’.Eachrecordwassplitinto 1-hperiodsandepisodescontainingEEGartefacts (disconnections or body movement) were visually identified (blind) and omitted from further analysis. Becauseofexcessivenoisyevents,oneanimalwas discarded in histamine 30c group. The 280 series of 1 h data(35ratsx8hperrat)weresubjectedtoafast fourier transform (FFT) algorithm and the spectral density was computed for the specified bands in every file (STATISTICAs, StatSoft, Tulsa, OK, USA). Due to different lengths of noisy periods, the records were of different sizes. In order to have a common reference, the spectral density in the delta band was analyzed as percentage of the spectral density in the whole frequency range (0–2.5 Hz). Analysis of data Results arose from a between–groups and repeated measures approach, comparing the mean value in the groups, but considering their own baseline record as SOLVENT Homeopathy 90 90 88 88 86 86 84 84 82 82 80 80 78 78 76 76 74 74 72 72 70 70 68 68 (a) HISTAMINE PRETREATMENT/HISTAMINE 30c (b) 90 88 86 84ec ddd84 c c d 82 d 80 78 76 74 72 70 68 (c) c ecd 90 88 86 82 80 78 76 74 72 70 68 (d) BASELINE AND POSITIVE ip CONTROL BASELINE SALINE ip Histamine ip ARTICLE IN PRESS Figure 1. Variation for spectral density in delta band in all groups. Mean spectral density, sd vs time, t. sd (%) in y-axis, time in hours in the x-axis from t 1⁄4 0 to 8. Each value is mean 7 SEM in (a–c). A similar pattern is seen in (a–c); histamine 30c exhibits, at t 1⁄4 1; 2 the lowest value as well as the greatest increase rate in the middle stage. As time goes on, all groups tend to baseline state. In (d), baseline exhibits a moderate enhancement up to t 1⁄4 5; a slight decrease tendency is developed after that, as expected in the absence of sleep disturbance. A similar pattern is observed for all ‘positive’ controls, which overlapped. aDifferent from baseline, Po0:01; bPo0.05. cDifferent from solvent, Po0:01; dPo0.05. eDifferent from histamine 30c, Po0:01: well. Comparison between-groups was by ANOVA, specifying the repeated measures (ie baseline/stimulus) as the within-subject factor. A multiple comparison procedure, the Newman–Keuls post-hoc test, was performed to determine significant differences between pairs of the three experimental groups. To avoid bias duetoextremevalues,outliersthatwereoutsidethe rangeof72sd,wereidentifiedandexcluded:3,2and 1 in solvent, histamine 30c and histamine pre- treatment/ histamine 30c groups respectively. Statis- ticalanalysiswascarriedoutwithSTATISTICAs. Results 1. Solvent orally: Sleep disturbance due to oral dosing was seen, but no other significant difference from baseline was measured. In fact, the spectral density in delta band increases smoothly from a minimum at t 1⁄4 1 (t 1⁄4 time in hours), due to repetitive awakenings for oral administration, to a maximum at t 1⁄4 5; a small decrease was observed during the following 3 h, as expected from the circadian pattern24 (Figure 1a). 2. Histamine 30c orally: Spectral density in the delta band was less than solvent through the whole HISTAMINE 30c c a b c d d d recording period, the difference was highly significant ðPo0:01Þ during the first 4 h. However, if was different from baseline only in the first 2 h (Figure 1b). 3. Histamine pre-treatment/ histamine 30c: This group was significantly different from solvent through- out , but there was no difference from baseline at any time. The difference from the histamine 30c group was significant only in the first 2 h (Figure 1c). 4. Positive controls: histamine and saline i.p.: Baseline recordings showed a slight increase in delta spectral densityatt1⁄42;afterwards,asmoothtendencyto decline was observed. A similar pattern was seen for the positive controls, no differences from baseline were detected at any time. Since delta activity subsides spontaneously from the first to the second non-REM stage in absence of sleep deprivation24 the baseline pattern is as expected outcome when there is no sleep loss. The ‘positive’ control (histamine i.p. only) results were as expected, since i.p. histamine does not cross the blood brain barrier (Figure 1d).25,26 Three time periods were identified: 1. t 1⁄4 022: Oral dosing was given in period. Highly significant differences ðPo0:01Þ; were found for histamine 30c compared to both baseline and solvent. The pre-treated group was not different from its baseline. Solvent values were approximately con- stant. 2. t 1⁄4 225: During this stage the host response to sleep deprivation was observed; a continuous increase in the spectral density in delta band was observed for the two histamine 30c groups but not in positive controls (which has not suffered sleep deprivation due to dosing) (Figure 1d). A linear relationship between log(spectral density, sd) vs log(time, t) was found. Figure 2 shows the fitting parameters and the correla- tion between experimental data (full line) and the linear model (dashed line). The function is presented as the general form log y1⁄4bþm log x, Histamine 30c PreTreat/Hist 30c Solvent 4.50 4.46 4.42 4.38 4.34 4.30 4.26 0.6 0.8 1.0 1.2 log (time, t) Solvent: log(sd) = 4.41 + 0.04*log(t), R = 99.4% Hist pre-treat: log(sd) = 4.32 + 0.06*log(t), R = 99.3% HIstamine 30c: log(sd) = 4.19 + 0.15*log(t), R = 97.9% Solvent Hist pre-treat/histamine 30 Histamine 30c 1.4 1.6 1.8 Figure 2. Log–log fitting for mean spectral density in delta band. log (sd) vs log (t) from t 1⁄4 2 to 5. Linear fitting was chosen because of its high correlation, R. Fitting function as dashed line. ARTICLE IN PRESS this time 0 2345 2345 2345 Figure 3. Rate of change for the spectral density in delta band. Time in hours in the x-axis. Values of histamine 30c group and pre-treated group are approximately 3.5 and 1.5 times those of solvent respectively. There is a decreasing trend from maximum at t 1⁄4 2; ie, immediately after the end of dosing. The changes evaluated are d(sd) during a time interval dt in Eq. (1) for each group. where y1⁄4sd; x1⁄4t; m1⁄4slope, b1⁄4intercept with y-axis. The Quasi-Newton method was employed in the regression parameters estimate, calculations were performedwithSTATISTICAs.Thisrelationcanbe changed to the form y 1⁄4 Cxa (1) where C 1⁄4 ExpðbÞ;a 1⁄4 m. The change rate, in this interval, was also calculated from dy/dt in the Eq. (1) for each group. Changes in the stimulated groups were different from those of solvent. These results are shown in Figure 3 where a gradual decrement is observed in all groups. The rate for histamine 30c was the greatest; it was approxi- mately 3.5 times faster than solvent; in contrast, histamine pre-treatment/ histamine 30c group rate was E1.4 times faster than solvent. 3. t 1⁄4 528: The rising spectral density seen in the precedingperiodstopped;insteadasmoothdeclining tendency begun. No difference from baseline was identified for histamine 30c and histamine pre-treat- ment/ histamine 30c groups, but they remained significantly different from solvent control. Discussion The statistical analysis compared the values of treatmentgroupswiththoseofsolventcontroland their own pretreatment baseline. The three treatment groups were under similar experimental conditions, ie., repetitive sleep disturbance for oral dosing (each 20min for the first 2h). Hence, it was expected that three groups developed a similar trend in time, which in fact they did (Figure 1). The consistency of the solvent group through the whole period implies the lack of treatment effect: the values were similar to Biological effect of highly diluted histamine G Ruiz-Vega et al 6 5 4 3 2 1 89 log (spectral density, sd) Homeopathy 90 Biological effect of highly diluted histamine G Ruiz-Vega et al baseline. These results confirm the accuracy of the selected marker. The histamine 30c results demonstrate that ULD histamine modifies the sleep pattern; the decrease in spectral density during the first 2h in histamine 30c group agrees with the experimental hypothesis suggest- ing an increase in wakefulness. The sleep pattern is characterized by three major rhythms: delta, slow (E0.3Hz) and spin spindle rhythms;27 however, the spectral density in delta band characterizes the system behavior under sleep perturbation. The histamine pre-treated (6 mg/kg i.p.) group also exhibited an initial decrement in the spectral density, however in contrast with histamine 30c it was not different from baseline. In order not to overestimate the possible effect of the highly diluted histamine in these rats, additional ‘positive’ controls were included (histamine 6mg/kg i.p. and saline i.p.). This was to control for the effect of histamine i.p. alone without any sleep disturbance due to oral administration. These results confirm the accuracy of the outcome measuresincesleeplosswasnotdetectedwithi.p. histamine (Figure 1d); this conforms with the conven- tional blood brain barrier model.25,26 The experimental results with the administration of the combination of two doses19,20 ie. pharmacological/ ULD doses, suggest that the ULD dose neutralizes the action of the substantial dose. However, i.p. histamine alone had no effect (Figure 1d). We cannot claim neutralization of non-existent effect! It would be possible to suggest that pharmacological dose has inhibited the response to the ultra-low-dose stimulus. Additional work is required to address this issue. TheEq.(1),y1⁄4Cxa;correspondstothegeneral form of the mathematical relations known as power laws; their main feature is self-similarity or scale invariance,28inturnassociatedwithfractality.The fractal concept was coined to describe irregular geometric forms that lack a characteristic (single) scale of length, but can also be applied to self-similar phenomena evolving in time.29,30 The expression self- organized critically (SOC) has been introduced,31 to describe the tendency of dissipative systems to drive themselves to a critical state, which is identified as an attractor for the dynamics. Power laws are ubiquitous in nature; they have been identified in diverse natural phenomena including the restoring force in a linear spring, Newton’s law of gravity, membrane channel openings, human writing, biological evolution, eco- nomics, music, earthquake structure, etc., which suggest that SOC might be an universal phenomen- on.28,29 The three experimental groups show a SOC tendency. They evolved between two different homeo- staticstates,bothofthemattainedspontaneouslyand conventionally recognized:32 (1) The conscious state of quiet wakefulness through the first 2h when the subject was disturbed by dosing ARTICLE IN PRESS every 20min; hence, the sleep cycle was prevented from evolving in spite of the animal being at the beginning of its circadian sleep cycle. (2) The unconscious stable state of NREM sleep in the last 3 h, which is asymptotically reached. Because of this feature, it is identified as a globally stable and attractive state. After the stimulus administration, the system spon- taneously evolved to NREM sleep, characterized by the dominance of delta rhythm. The immediate response system, between t 1⁄4 2 and 5, evolved accord- ing to a power function. The periods of transition from an active to a resting state are described by an asymptotic decline of the variable (metabolic rate, breathing rate and tidal volume), such asymptotic decrease is characterized by the change of rate which gradually evolves from a maximum to a minimum when the system approaches to the lowest value and reaches the resting state.32 In our case, the variable does not decline, because deltaoscillationsarethemainfeatureofNREMsleep, its prevalence (expressed as the percentage) in contrast, increases. However, as time goes by, the rate of change diminished as it gets closer to its final value (Figure 3). Because the rate of change in the histamine 30c group was significantly higher than solvent, a synergic effect of the ultra-low-dose stimulus may be suggested. In addition, when certain final state is specific for a given system in determined circumstances, no matter the initial conditions, the tendency to reach such a steady state is termed ‘equifinality’.32 Because from different initial conditions the three experimental groupsevolvedtoreachthesameequifinalstate(ie, no difference from baseline), it is assumed that the system has been self-organized in time to reach a global attractor,whichinturnimpliesfractality.Theadapt- ability of response is crucial to confer robustness under unexpected circumstances. Robustness and fractality are generic characteristics of SOC,33 it is not unreason- able to think of homeostasis as a fractal process for restoring the dynamics of health. The concept of fractal physiology30 as adaptive processes which guarantee to respond to unpredictable stimuli and stresses is widely accepted. The high correlation between our experimental data and the SOC model suggests that the system has evolved from one state to another one according to a power law. Conclusion These results suggest that histamine 30c induced not only a transient sleep loss, reflected by the initial decreaseinthespectraldensityindeltaband,butalsoa synergic effect on the immediate host response. A self- similar pattern was identified after dosing: the system evolved driven by a threshold dynamics between two critical states; which implies the organism was impelled Homeopathy 1 Khandelwal JK, Hough LB, Green JP. Histamine and some of 60:914–918. 2 Babe KS, Serafin WE. Histamine, bradykinin, and their antagonists. In: Goodman & Gilman’s, The Pharmacological Basis of Therapeutics. New York: McGraw Hill, 1996, pp. 581–593. 3 Toyota H, Dugovic C, Koehl M, Laposky AD, Weber C, Ngo K, Wu Y, Lee DH, Yanai K, Sakurai E, Watanabe T, Liu C, Chen J, Barbier AJ, Turek FW, Fung-Leung WP, Lovenberg TW. 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Journal of the Australian Traditional-Medicine Society September 2007 Volume 13 Issue 3 Update On Research

Journal of the Australian Traditional-Medicine Society September 2007 Volume 13 Issue 3Update On Research In Homœopathy Robert Medhurst Previous issues of this journal contained summaries of some of the more notable pieces of research carried out on homœopathy and as a means of keeping you up to date on this subject, more of these follow. If you use homœopathy in your clinical practice this sort of information is useful to be aware of. Those of us who practise this modality are often asked to justify it by something other than anecdote, and given the difficulty that orthodox medicine and science has in accepting a mechanism for it, controlled clinical evidence in homœopathy is of great help in being able to do this. Human Studies Frass M, Linkesch M, Banyai S et al. Adjunctive homeo- pathic treatment in patients with severe sepsis: a ran- domized, double-blind, placebo-controlled trial in an intensive care unit. Homeopathy 2005;94(2):75—80. In this study, 70 people admitted to an intensive care unit suffering from severe sepsis were treated either with individ- ualised homœopathic treatment or placebo. On reviewing the signs of sepsis, organ failures, need for mechanical ventila- tion and other parameters at 180 days after beginning treat- ment, 76% of the patients using homœopathy met survival criteria versus 50% of those on placebo. Frei H, Everts R, von Ammon K et al. Homeopathic treatment of children with attention deficit hyperactivity disorder: a randomised, double blind, placebo controlled crossover trial. Eur J Pediat 2005;164(12):758—767. Eighty-three children diagnosed as suffering from ADHD using DSMIV criteria were treated with individually pre- scribed homœopathic medicines. Using the Connor’s Global Index scale it was determined that 63 of these children responded to treatment. These children were then ran- domised to receive either placebo or homœopathic medi- cines for 6 weeks and at this point were crossed over to receive placebo if they had been using the homœopathics or vice versa. At the end of this period it was found that homœopathic therapy provided significantly better results than placebo. Haila S, Koskinen A, Tenovuo J. Effects of homeopathic treatment on salivary flow rate and subjective symptoms in patients with oral dryness: a randomized trial. Homeopathy 2005;94(3):175—181. In this blind, placebo-controlled study, 28 people diagnosed with xerostomia (dryness of the mouth) were randomly assigned to receive either placebo or individually prescribed homœopathic medicines. Assessed using unstimulated and wax-stimulated salivary flow rates and visual analogue scales at the end of the trial, only 26 of those people using homœopathic treatment and none using placebo were found to have had significant relief. Following the assessment of these results those on placebo were switched to homœopath- ic therapy, after which all experienced relief from their xerostomia. Sevar R. Audit of outcome in 455 consecutive patients treated with homeopathic medicines. Homeopathy 2005;94(4):215—221. This study examined the effect of individualised homœo- pathic treatment of 455 consecutive patients in a homœo- pathic medical clinic who had previously had unsuccessful orthodox medical treatment or were considered to be unsuit- able for orthodox medical treatment. Of these, 67% derived benefit from homœopathic therapy, and 33% were able to stop or maintain a substantial reduction in their pharmaceu- tical drug therapy. Baars EW, De Bruin A. The effect of Gencydo injections on hayfever symptoms: a therapeutic causality report. J Altern Complement Med 2005;11(5):863—869. In this study, 13 Dutch medical practitioners submitted patients (who between them had a mean history of hayfever of 9 years) for therapy involving injections of Gyncedo, a combination homœopathic product. All but one patient were given the medication before the onset of the hayfever season and all were given it during the hayfever season. Of these 13, during the course of the trial 9 people found no increase in nasal and non-nasal hayfever symptoms when the hayfever season began or during it and only 1 of the 13 felt compelled to use conventional hayfever medication. Animal Studies Ruiz-Vega G, Poitevin B, Perez-Ordaz L. Histamine at high dilution reduces spectral density in delta band in sleeping rats. Homeopathy 2005;94(2):86—91. Histamine in material doses is a central nervous system stim- ulant operating via H1 receptors. The researchers in this study examined the effects of histamine in 30C homœopath- ic potency on the sleep patterns of rats. Using the spectral density of the delta band in the sleep electroencephalogram to measure the effects of the remedy, which is higher during periods on non-REM sleep, researchers found that histamine 30C produced an increase in wakefulness when compared to controls. Sukul NC, Ghosh S, Sinhababu SP. Reduction in the number of infective Trichinella spiralis larvae in mice by use of homeopathic drugs. Forsch Komplementarmed Klass Naturheilkd 2005;12(4):202—205. Trichinellosis, a disease caused by Trichinella spiralis which occurs in humans and animals, was the subject of this trial. Mice infected with this organism were given Podophyllum mother tincture, Cina 30C, Santonin 30C, or ethanol 30C as 155 Journal of the Australian Traditional-Medicine Society September 2007 Volume 13 Issue 3 a control substance. After 120 days the mice were examined for the presence of the T. spiralis larvae and this was com- pared with the larval load before therapy. At 120 days the mice given Podophyllum had their larval load reduced by 61% when compared to the control, those given Santonin had a reduction of 81% and the mice given Cina had a reduc- tion of 84%. Aziz DM, Enbergs H. Stimulation of bovine sperm mito- chondrial activity by homeopathic dilutions of monensin. Homeopathy 2005;94(4):229—232. Mitochondrial activity is an important marker for the health of sperm. It is linked to sperm motility and in research labo- ratories monensin is commonly used as an inhibitor for sperm mitochondrial activity. The researchers in this study examined the effects of the 5th to the 14th decimal potencies of monensin on the activity of the mitochondria of sperm taken from mature bulls. All of the potencies produced a stimulatory effect on the bull sperm mitochondrial activity, with the 9X producing the strongest of these effects. Plant Studies Brizzi M, Lazzarato L, Nani D, Borghini F, Peruzzi M, Betti L. A biostatistical insight into the As(2)O(3) high dilution effects on the rate and variability of wheat seedling growth. Forsch Komplementarmed Klass Naturheilkd 2005;12(5):277—283. Wheat seedlings previously stressed with sub-lethal doses of arsenic, a substance known to be lethal to this plant, were treated with various potencies of Arsenicum album (5X, 15X, 25X, 35X and 45X), equivalent potencies of water and- equivalent unsuccussed dilutions of arsenic trioxide. The stem lengths of the seedlings was assessed at day 7 and it Medhurst R. Update on Research in Homœopathy. was found that the 45X potencies of Arsenicum and the water but not the diluted arsenic trioxide induced an increase in seedling height. Binder M, Baumgartner S, Thurneysen A. The effects of a 45x potency of Arsenicum album on wheat seedling growth — a reproduction trial. Forsch Komplement- armed Klass Naturheilkd 2005;12(5):284—291. In a repeat performance of the previous trial, wheat seedlings previously exposed to sub-lethal doses arsenic were cultivat- ed in either Arsenicum album 45X, water 45X or unpoten- tised water, and the seedling height measured at 7 days. The experiment was independently reproduced 8 times and after the results were collated the wheat seedlings cultivated in Arsenicum 45X showed a significant reduction in height when compared to the 2 controls. This is a reversal of results seen in previous studies of this type, but does confirm a reproducible effect of this particular homœopathic medicine under these experimental conditions. In Vitro Studies Oberbaum M, Glatthaar-Saalmüller B, Stolt P, Weiser M. Antiviral activity of Engystol: an in vitro analysis. J Altern Complement Med 2005;11(5):855—862. Cultured tissue cells infected with Herpes simplex virus 1 (HSV-1), human rhinovirus (HRV), adeno 5 (A5V) and res- piratory syncitial virus were exposed to Engystol, a homœo- pathic combination product. These cells were then assayed for virus clearance using plaque reduction, virus titration and Elisa methods. The results of these assays showed an 80% reduction in HSV-1 specific proteins, a 73% reduction in A5V specific proteins and a reduction in infectivity of RSV by 37% and HRV by 20%.􏰎 The ATMS Simon Schot Education Grants ($10,000) Proudly sponsored by Marsh (ATMS insurance broker) What is the Purpose of the Grants? The purpose of the grants is to encourage and assist 10 ATMS accredited members to undertake further education in complementary medicine. The grants will subsidise a diploma course or higher qualification course at an ATMS recognised course or a research project in com- plementary medicine at an appropriate tertiary institution. How Do the Grants Work? The grants consist of 10 prizes of $1,000 each. The grants will be paid direct- ly to the institution. The ten winners will be decided by a draw to be held in March 2008. For demographic reasons, no less than 5 winners will be residents of NSW. How To Apply for the Grants? The grants are open to all ATMS Accredited members. To apply send a let- ter to ATMS with your name, address, telephone number, ATMS membership number and the name of the ATMS accredited course or research project you wish to undertake if successful. The winners must com- mence the course no later than 2009. Send your letter to: Simon Schot Education Grant, ATMS, PO Box 1027 Meadowbank NSW 2114 Telephone (02) 9809 6800, fax (02) 9809 7570, email: marie@atms.com.au The deadline to apply for the Education Grants is 1 March 2008 156 

Repetitions of fundamental research models for homeopathically prepared dilutions beyond 10-23: a bibliometric study

Int J High Dilutions Res 2011; 10(35):78-78 Proceedings of the XXIV GIRI Symposium; 2010 Nov 05; Monte Carlo (Monaco)Repetitions of fundamental research models for homeopathically prepared dilutions beyond 10-23: a bibliometric study Peter Christian Endler Interuniversity College Graz, Castle of Seggau, Austria ABSTRACT Introduction: Repeatability of experiments is an important criterion of modern research and a major challenge for homeopathic basic research. There is a lack of a recent overview about basic research studies in high homeopathic potencies that have been subjected to laboratory-internal, multicenter or independent repetition trials. Methods: We considered biochemical, immunological, botanical, cell biological and zoological studies on high potencies, i.e. beyond a dilution of 10-23. Main sources of information were reviews, personal contact with members of the homeopathic basic research community, and the MEDLINE and HOMBREX databases. Studies were extracted from the publications and grouped into models. Studies were further sorted according to repetition type (laboratory-internal, multicenter, or independent) and results achieved. Results: A total of 107 studies have been found. From these, 30 were initial studies. In the attempt to reproduce one of these initial studies, 53 follow up studies yielded comparable effects (35 laboratory- internal, 8 multicenter, 10 independent repetitions), eight studies showed a consistent, yet different result from the initial study (2 laboratory-internal, 2 multicenter, 4 independent repetitions), and 16 studies yielded zero effects (5 laboratory-internal, 2 multicenter, 9 independent repetitions). When all repetitive studies are considered, 69% reported effects comparable to that of the initial study, 10% different effects, and 21% zero effects. Independently performed repetition studies reported 44% comparable effects, 17% different effects, and 39% zero effects. Conclusions: We identified 24 experimental models in basic research on high homeopathic potencies, which were repeatedly investigated. 22 models were reproduced with comparable results, 6 models with different results, and repetition showed no results for 15 models. Independent reproductions with either comparable or different results were found for seven models. We encourage further repetition trials of published studies, in order to learn more about the model systems used and in order to test their repeatability [1]. [1] Endler PC, Thieves K, Reich C, Matthiessen P, Bonamin L, Scherr C, Baumgartner S. Repetitions of fundamental research models for homeopathically prepared dilutions beyond 10-23: a bibliometric study. Homeopathy. 2010; 99: 25-36. Licensed to GIRI Support: authors declare that this study received no funding Conflict of interest: authors declare there is no conflict of interest Correspondence author: P. Christian Endler, college@inter-uni.net , http://www.inter-uni.net How to cite this article: P.C Endler. Repetitions of fundamental research models for homeopathically prepared dilutions beyond 10-23: a bibliometric study. Int J High Dilution Res [online]. 2011 [cited YYYY Month dd]; 10(35): 78-78. Proceedings of the XXIV GIRI Symposium; 2010 Nov 05; Monte Carlo (Monaco). GIRI; 2010. [cited YYYY Month dd]; Available from: http://www.feg.unesp.br/~ojs/index.php/ijhdr/article/view/441/470 78 Copyright of International Journal of High Dilution Resarch is the property of International Journal of High Dilution Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

An Exploratory Study on Scientific Investigations in Homeopathy Using Medical Analyzer

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 17, Number 8, 2011, pp. 705–710a Mary Ann Liebert, Inc. DOI: 10.1089/acm.2010.0334 Abstract An Exploratory Study on Scientific Investigations in Homeopathy Using Medical Analyzer Nirupama Mishra, MD(Homoeo),1 K. Charan Muraleedharan, MD(Homoeo),1 Akalpita Sriniwas Paranjpe, PhD,2 Devendra Kumar Munta, MD(Homoeo),1 Hari Singh, BSc(Hon), DHMS,3 and Chaturbhuja Nayak, MD(Homoeo)3 Background: The action of homeopathic medicines, in ultra-high dilution, is not directly observable. An attempt was made to explore autonomic response of selective homeopathic medicines, in healthy persons, using Medical Analyzer System (Electronics Division, Bhabha Atomic Research Centre, Mumbai, India). Objective: The objective of the study was to observe the action of homeopathic medicines on physiologic variability of heart rate and blood flow. Material and methods: Pre- and postinterventional variability spectra of heart rate and blood flow of 77 subjects were recorded with the Medical Analyzer System, administering homeopathic preparations of Aconitum napellus (6c, 10M), Arsenicum album (200c, 1M), Gelsemium sempervirens (200c, 1M), Phosphorus (200c, 1M), Pulsatilla nigricans (200c) and Sulphur (200c, 1M) versus placebo control. The amplitude of the peaks viz. low-frequency, medium-frequency, and high-frequency was measured for postintervention analysis. An increase in the am- plitude of any valid peak by 100% or a decrease by 50% was considered as significant change. Results: Aconitum napellus produced a response in heart rate variability (HRV) with 30c potency and in blood flow variability with 1M potency. Sulphur 200c and 1M, Gelsemium 200c and Pulsatilla 200c, produced a 62.5% response in HRV against the placebo response of 16.6%. Gelsemium, Phosphorus, and Sulphur produced a re- sponse in blood flow variability with a 1M potency, similar to the response of Aconitum napellus 1M. Conclusions: These data suggest that it is possible to record the response of homeopathic medicines on physi- ologic parameters of the autonomic nervous system. Introduction Even while constitutional medicines offered by the homeopathic system of medicine have subjectively es- tablished their curative value over the past 2 centuries, the system has not found wide acceptance, mainly due to paucity of objective scientific data. The concentration of medicinal substance in 1 g of homeopathic preparation of 12c or above is less than 1 · 10 - 24 g, which is beyond the material existence as per Avogadro’s number, and hence, cannot contain a single molecule of the medicinal substance. Since analytical methods are the prerequisite for obtaining any scientific data, several attempts were made in the past to establish analytical meth- ods on homeopathic potencies. Spectroscopic analysis with nuclear magnetic resonance or infrared1–4 did not show any significant difference in the spectrum of pure carrier solvent material (alcohol) and homeopathic preparation. Paranjpe5 gave a physicist’s view to the action of homeopathic medi- cines. Using antigen–antibody reaction, Davenas et al. re- ported a positive reaction with homeopathic dilutions of antibodies (dilution with agitation), which was absent in - 120 simple dilutions up to a concentration of 10 . They also observed the necessity of - OH group in the solvent for ob- taining a positive antigen–antibody reaction.6 However, these experiments could not be reproduced. A new technique, physiologic variability analysis, can study the functioning of the autonomic nervous system (ANS) through variations in a physiologic parameter in a subject resting in the supine position to estimate the input contribution of different body systems to ANS.7 Several other studies have indicated that diseases of different organs of the body such as diabetes mellitus, myocardial infarction, hyperthyroidism, tuberculosis, and autoimmune deficiency syndrome cause specific alterations in physiologic parameters’ variability.8–11 Jindal et al. measured central and peripheral blood flow using impedance plethysmography (IPG), before 1Regional Research Institute for Homoeopathy, CCRH, Mumbai, India. 2Bhabha Atomic Research Centre, Mumbai, India. 3Central Council for Research in Homoeopathy, New Delhi, India. 705 706 MISHRA ET AL. and after the administration of homeopathic medicines to pa- tients. They recorded increase in blood flow with Sepia officinalis CM and Sulphur 1M.12 As a natural extension of these obser- vations, Jindal et al. had recorded heart rate variability (HRV) and blood flow variability (BFV) after administration of Sulphur 1M, Gelsemium 10M, and Phosphorus 30c and observed unique changes.13 The Central Council for Research in Homoeopathy, India, took the initiative to extend these studies with a predefined protocol and meticulous methodology at the Regional Re- search Institute of Homoeopathy, Mumbai. The present article describes the effect of homeopathic potencies of Aconitum napellus, Arsenicum album, Gelsemium sempervirens, Phosphorus, Pulsatilla nigricans, and Sulphur on HRV and BFV. Objective The objective of this investigation was to observe the changes produced in the variability spectrum of HRV and BFV following administration of placebo and different po- tencies of certain homeopathic medicines. Materials and Methods The study group comprised 77 healthy volunteers ages 18–35 years. Laboratory investigations such as complete blood count, erythrocyte sedimentation rate, liver function tests, renal function tests, blood glucose level, serum lipid profile, electrocardiogram, and chest radiograph were done for all the subjects whose written consent was obtained after explaining the details of the study. Medical Analyzer System (Electronics Division, Bhabha Atomic Research Centre, Mumbai, India) records the vari- ability spectrum of heart rate and peripheral blood flow. This system is based on the principle of IPG and records blood volume changes in any part of the body noninvasively by measuring its electrical impedance, which is inversely pro- FIG. 1. Heart rate variabil- ity (HRV) spectrum in a con- trol subject. The lower graph shows HRV in the time do- main and the upper one shows the same in the fre- quency domain. The complex time domain variations lead to definite peaks in the fre- quency domain. The peaks, their amplitudes, and power are given in the table at the bottom of the figure. portional to blood volume changes. The rate of change of impedance thus gives the rate of change of blood volume. The pulsatile blood flow during ventricular systole is reflected as well-formed peaks in IPG, and the instantaneous heart rate is derived from the time elapsed between two consecutive peaks. The blood flow index (blood flow in milliliters per 1000 cm3 of body tissue per cardiac cycle) is obtained from the amplitude of the peak and gross electrical impedance of the body segment.10 A 5-minute record of instantaneous heart rate and blood flow values thus obtained is interpolated to obtain periodic values of these parameters as a prereq- uisite before Fourier transformation. The subsequent Four- ier transform depicts the contribution of various rhythms that cause variability in the physiologic parameters and re- presented by low-frequency (L), medium-frequency (M), and high-frequency (H) peaks (Fig. 1). ‘‘L’’ generally denotes sympathetic action, whereas ‘‘M’’ and ‘‘H’’ denote parasym- pathetic and/or vagal action. In view of the multiple readings required in this protocol, the system software was upgraded to incorporate the average variability spectrum, for HRV and BFV obtained from multiple readings in situ, pre- and post- intervention, and display these on a PC monitor.14 Medicines coming in the top grade on repertory search related to cardiorespiratory functions such as variations in pulse, respiration, breathing, and so on were considered for deciding on trial drugs. For rubric selection, ‘‘Complete Repertory’’ by Roger van Zandvoort15 was consulted. In such a group, both polychrests as well as remedies having specific action on these parameters were included. As pla- cebo, plain globules soaked with dispensing alcohol were used. Since it was an exploratory study, two different pro- tocols were followed for the experiments. Protocol 1 was designed for the Aconitum napellus group of 27 subjects. On the first day, pre- and postintervention data for placebo were obtained. Placebo was replaced by Aconite 6c, Aconite 30c, Aconite 200c, Aconite 1M, and Aconite 10M on  HOMEOPATHIC MEDICINES, HEART RATE VARIABILITY, BLOOD FLOW VARIABILITY 707 the 2nd, 3rd, 4th, 5th, and 6th days, respectively. Data analysis was done for each of the days. Protocol 2 was designed for a group of 50 subjects and com- prised Arsenic 200c (n = 5), Arsenic 1M (n = 5), Gelsemium 200c (n = 5), Gelsemium 1M (n = 5), Phosphorus 200c (n = 5), Phosphorus 1M (n = 6), Pulsatilla 200c (n = 4), Sulphur 200c (n = 10), and Sulphur 1M (n = 5). In this case, pre- and postintervention data were recorded with placebo on the 1st day and with any one of the selected medicines and potency on the 2nd day. Since the study has been exploratory in nature, it was the intention of the authors to investigate all possibilities under this study. Protocol 1 was designed to meticulously investi- gate the effect of a particular medicine in different potencies. Protocol 2 was designed in such a manner that a large number of medicines could quickly be screened for their action on variability spectrum. Data for both of the protocols were collected as follows. With the subject in the supine position, the IPG signal was recorded from the wrist of the subject for 5 minutes and three such consecutive observations were taken. The subject was then administered the desired substance (placebo or medi- cine) followed by recording of three similar readings again to obtain the postintervention data of HRV and BFV. The pre- and postintervention data were then analyzed using the software described above, which gave out average spectra of multiple readings. In the postintervention analysis, a change was considered significant if the amplitude of any valid peak either increased by 100% (designated as ‘‘+’’) or decreased by 50% (desig- nated as ‘‘-’’) as compared to the pre-intervention amplitude. These high thresholds were intentionally fixed in order to have reliable findings. Amplitude of the peak had been chosen for postintervention analysis in place of area under the same because the former had the advantage of noise elimination. A postintervention decrease in the first peak (L-) and increase in the third peak (H + ) were discarded because these changes commonly occur due to prolonged rest. Results Typical pre- and postintervention average variability spectra are depicted in Figures 2 and 3. As can be seen from Figure 2, the placebo has not elicited any response in either spectra (HRV or BFV). The medicine has produced change in both HRV and BFV as illustrated in Figure 3. Table 1 summarizes the results of intervention in HRV. Under Protocol 1, Aconite 30c has shown response in HRV. From Protocol 2, it is seen that the maximum response has been obtained in 200c potency, namely, Gelsemium 200c, Pulsatilla 200c, and Sulphur 200c accounting for 68.42%. The exception in this group is Sulphur 1M, which has shown some response in HRV and together, they account for 62.5% response in HRV as against 16.6% of placebo response. Table 2 summarizes the response in BFV. From Protocol 1, Aconite 1M has shown response in BFV in 53.9% of the study sample as against placebo response of 25.92%. From Protocol 2, Gelsemium 1M, Phosphorus 1M, and Sulphur 1M have shown response in BFV, the exception here being Phosphorus 200c, which has shown a similar response. Response produced by medicines is 40% as against placebo response of 0%. Other potencies of Aconite from Protocol 1 and both po- tencies of Arsenic in Protocol 2 have not shown any response either in HRV or in BFV. Discussion This exploratory study on HRV and BFV with homeo- pathic medicines on a defined protocol was the first of its kind using average spectra of multiple readings. The results show that certain medicines and potencies have action on either HRV or BFV (Tables 1 and 2). Though the study was on an elaborate scale with defined protocol and multiple readings per setting, it was still ex- ploratory in nature and, therefore, the study protocol and interpretation of results were not strictly in conformity with conventional pharmacologic trials of modern medicine. Some deviations were made in the analysis of variability data. Hitherto, the variability spectrum was analyzed on the basis of area under different peaks, which represents the contribution of a particular rhythm in autonomic control. Though this approach has the simplicity of machine-generated results, it completely overlooks the amplitude of a particular peak, which signifies the coordination of a particular rhythm in autonomic control. For instance, a narrow peak with high amplitude may have the same area as that of a very broad peak with very low amplitude; in reality, the narrow peak with high amplitude represents better coordination in the ANS. This has led to using the amplitude of the peak in variability spectrum to differentiate the response. Furthermore, the spectrum was analyzed between 0.02 Hz and 0.50 Hz as compared to the FIG. 2. Pre- and postplacebo heart rate variability (HRV) and blood flow variability (BFV) average spectrum. The graphs on the top give HRV and BFV before and the ones in the bot- tom give HRV and BFV after placebo. There was a 20% de- crease in the first peak in the HRV spectrum, which is not significant. Similarly, there is a 25% increase in the first peak in the BFV spectrum, which is also not significant as per the crite- ria.  708 MISHRA ET AL. FIG. 3. Pre- and post- intervention average spectrum of heart rate variability (HRV) and blood flow variability (BFV) after Sulphur 1M. In HRV, the third peak is decreased in amplitude to almost half, whereas in BFV the first peak amplitude has nearly doubled. 0.00–0.50 Hz conventionally used. This was because the zero frequency component of variability sometimes suppresses the higher frequency components and can lead to incorrect infer- ence. Since our interest was to study the various rhythms controlling ANS and not the zero frequency component, the deviation was justified. In conducting the experiments, even though a separate placebo group has not been tested, placebo was administered on the first day of the experiment and medicinal intervention on following day(s) in all the subjects, irrespective of the group or medicine they belong to. This was done so that subjects act as their own control because physiologic response of every individual is different even in similar circumstances. To keep the variables at minimum, in all the subjects the experiments were conducted under similar conditions, and for each individual, the same timing was maintained throughout the experiment. The experiment began with the Aconite group, as per Protocol 1, and various potencies were used in ascending order in each of the individuals. The observed outcome was potency specific. Aconite 30c produced a peak in HRV (Fig. 4A) and Aconite 1M produced a similar peak in BFV Table 1. Response in Heart Rate Variability After Intervention (Fig. 4B). It shows that Aconite acts at one level in 30c potency and another level in 1M potency. Other potencies did not show any remarkable changes either in HRV or BFV. The results in the second group of subjects under Protocol 2 also revealed similar observations. Gelsemium 200c, Pulsa- tilla 200c, Sulphur 200c, and Sulphur 1M (1M potency is an exception here) produced response peaks in HRV (Table 1) and Gelsemium 1M, Phosphorus 1M, Sulphur 1M, and Phos- phorus 200c (200c potency is an exception in this group), produced response peaks in BFV (Table 2). Arsenic did not produce any response in either of the potencies. The obser- vations were consistent with those of Aconite: lower potency produced a response in HRV and higher potency produced a response in BFV, with the exception of Sulphur 1M in HRV and Phosphorus 200c in BFV. A pattern seems to emerge from these experiments: me- dium potencies such as 30c and 200c have probable action on HRV and higher potency such as 1M has probable action on BFV. It is noteworthy that HRV and BFV are derived from the same data, yet the changes produced in both are by different potencies of the same medicine. To illustrate, the change in HRV at Aconite 30c is not reflected in BFV, and Table 2. Response in Blood Flow Variability After Intervention Intervention Aconitum napellus 30c (27 subjects) Placebo Medicine Gelsemium 200c (5 subjects) Placebo Medicine Pulsatilla 200c (4 subjects) Placebo Medicine Sulphur 200c (10 subjects) Placebo Medicine Sulphur 1M (5 subjects) Placebo Medicine Total number of volunteers/ number responded (%) 27/12 (44.4%) 27/15 (55.5%) 5/1 (20%) 5/3 (60%) 4/1 (25%) 4/3 (75%) 10/1 (10%) 10/7 (70%) 5/1 (20%) 5/2 (40%) Intervention Aconite 1M (27 subjects) Placebo Medicine Gelsemium 1M (5 subjects) Placebo Medicine Phosphorus 1M (6 subjects) Placebo Medicine Phosphorus 200c (5 subjects) Placebo Medicine Sulphur 1M (5 subjects) Placebo Medicine Total number of volunteers/ number responded (%) 27/7 (25.92%) 26/14 (53.9%) 5/0 (0%) 5/2 (40%) 6/1 (16.66%) 6/2 (33.33%) 5/0 (0%) 5/2 (40%) 5/0 (0%) 5/2 (40%)  HOMEOPATHIC MEDICINES, HEART RATE VARIABILITY, BLOOD FLOW VARIABILITY 709 A. Heart rate variability (HRV) response to various eliminate subjective bias and objectively demonstrated the action of the homeopathic medicines. Second, responses were observed in 30c, 200c, and 1M potencies, which are well beyond Avogadro’s number. These are observations from exploratory experiments in emerging areas of physiologic variability and need validation by re- peated experiments of this type. Detection of response was the primary objective of this study, which has been achieved. The number of subjects in each group was small; hence it was not possible to show the statistical significance of the results, an aspect that is intended to be covered in future studies. Conclusions Selective response has been detected with the adminis- tration of different potencies of various homeopathic medi- cines in HRV and BFV, and the exploratory study has provided directions for future trials. Reproducibility of these observations in a larger sample size will be necessary for validation of this study’s results. Acknowledgments The authors are grateful to Dr. G.D. Jindal, Electronics Division, Bhabha Atomic Research Centre, Mumbai for pro- viding the expertise needed for the study. They thank all of the students, interns, and faculty members of CMP Homo- eopathic Medical College, Mumbai for enthusiastic participa- tion in the study as volunteers. The authors acknowledge the contributions of Mrs. Uma A. Clerk and other staff of the Regional Research Institute for Homoeopathy, Mumbai. Disclosure Statement No competing financial interests exist. References 1. Smith RB, Boericke GW. Changes caused by succussion on NMR patterns and bioassay of bradykin triacetate succes- sions and dilutions. J Am Inst Hom 1968;16:197–212. 2. Weingartner O. NMR features that relate to homoeopathic sulphur potencies. Berlin J Res Homoeopathy 1990;1: 61–68. 3. Anick DJ. High sensitivity 1H-NMR spectroscopy of homo- eopathic remedies made in water. BMC Complement Altern Med 2004;4:15. 4. Rey L. Thermoluminiscence of ultra-high dilutions of lithium chloride and sodium chloride. Physica A 2003;323:67–74. 5. Paranjpe AS. Action of homoeopathic medicines: A physicist view. Q Bull Central Council Res Homoeopathy 1989;10:26. 6. Davenas F, Beauvais F, Amara J, et al. Human basophil degranulation triggered by very dilute antiserum against IgE. Nature 1988;333:816–818. 7. Camm AJ, Malik M, et al. Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation 1996;93:1043–1065. 8. Bianchi A, Bontempi B, Cerutti S, et al. Spectral analysis of heart rate variability signal and respiration in diabetic sub- jects. Med Biol Eng Comput 1990;28:205–211. 9. Bigger JT, Fleiss JL, Steinman RC, et al. Frequency domain measures of heart period variability and mortality after myocardial infarction. Circulation 1992;85:167–171. 10. Jindal GD, Ananthakrishnan TS, Kataria SK, Deshpande Alaka K. An Introduction to Impedance Cardiovasography. FIG. 4. potencies of Aconite napellus. B. Blood flow variability (BFV) response to various potencies of Aconite napellus. change in BFV at Aconite 1M is not reflected in HRV. This may be indicative of the selective action of different potencies of the same medicine. Plotting of the same shows a peak in HRV response, with Aconite 30c (Fig. 4A) and a peak in BFV response with Aconite 1M (Fig. 4B). These peaks separate the response of Aconite 30 and 1M from the rest of the inter- ventions in this group. The response has been counted positive, irrespective of its nature. For instance, significant increase or decrease in either of the L, M, or H peaks has been counted as response. In future such studies, the authors may explore the possibility of analyzing response with respect to a particular peak or parameter. This was an exploratory study on variability in physio- logic parameters, conducted for the first time on this subject hitherto unexplored in a systematic manner with homeo- pathic medicines. Eliciting an autonomic tone of healthy subjects with the help of homeopathic medicine is a process similar to that of a ‘‘homeopathic pathogenetic trial’’ in which, when a medicinal substance is given to a group of healthy provers, some symptoms of the medicine are elicited in a number of proving subjects, yet there are few symptoms that appear in 1 or 2 subjects only. Some subjects do not prove any of the symptoms of a medicine. This perhaps ex- plains why some of the medicines/potencies did not show any response. A few observations emerge from the experiments. First, the autonomic nervous system is not under voluntary con- trol, and recording signals from the ANS immediately after intervention (within 5–15 minutes of intervention) helped 710 MISHRA ET AL. External Report, BARC/2001/E/003, 2001. Mumbai: Bhab- ha Atomic Research Centre. 11. Jindal GD, Ananthakrishnan TS, Mandlik Sadhana A, et al. Medical Analyzer for the Study of Physiological Variability and Disease Characterization. External report, BARC/2003/ E012, 2003. Mumbai: Bhabha Atomic Research Centre. 12. Jindal GD, Parajpe AS, Singh H, et al. Role of non-invasive techniques in the evaluation of non-conventional medicines. In: Proceedings, National Symposium Cum Workshop on Advances in Imaging and Image Processing, vol. VI. Mumbai: Biomedical Engineering Society of India, 1988; 9.1–9.9. 13. Jindal GD, Ananthakrishnan TS, Katara SK, et al. Objective monitoring of response of homoeopathic medicines using Med- ical Analyzer. Natl J Homoeopathy 2004;VI:206–207. 14. Jain RK, Sinha V, Mishra N, et al. Development of software for assessment of therapeutic response by physiological variability. IETE J Res 2008;54:223–230. 15. van Zandvoort R. Complete Repertory: CARA Professional, vol. 1.4. West Bridgeford, Nottingham, England: Miccant Ltd. Address correspondence to: K. Charan Muraleedharan, MD(Homoeo) Regional Research Institute for Homoeopathy CCRH Hall no. 4, Shopping Center, Sector 9, CBD Belapur Navi Mumbai 400 614, Maharashtra India E-mail: rrihmumbai@gmail.com Copyright of Journal of Alternative & Complementary Medicine is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument

BMC Health Services ResearchBioMed Central Research article Open Access Outcome related to impact on daily living: preliminary validation of the ORIDL instrument David Reilly*1, Stewart W Mercer2, Annemieke P Bikker1 and Tansy Harrison1 Address: 1AdHom Academic Departments, Centre for Integrative Care, Glasgow Homœopathic Hospital, 1053 Great Western Road, Glasgow G12 OXQ, Scotland, UK and 2General Practice and Primary Care, Division of Community-based Sciences University of Glasgow, Glasgow G12 9LX, Scotland, UK Email: David Reilly* - davidreilly1@compuserve.com; Stewart W Mercer - sm83z@clinmed.gla.ac.uk; Annemieke P Bikker - A.Bikker@btinternet.com; Tansy Harrison - tansyharrison@hotmail.com * Corresponding author Published: 2 September 2007 Received: 7 December 2006 BMC Health Services Research 2007, 7:139 doi:10.1186/1472-6963-7-139 This article is available from: http://www.biomedcentral.com/1472-6963/7/139 Accepted: 2 September 2007 © 2007 Reilly et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patient's views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care. Methods: In the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure. Results: Study 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores. Conclusion: There is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life. (page number not for citation purposes) Page 1 of 10 BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 Background The challenge of finding practical, patient-focussed, clini- cally-relevant outcome measures is a key issue in the increasing call for patient-centred care and clinical govern- ance in health systems around the world [1,2]. However, there are relatively few patient-rated outcome measures that seek to measure change from the patients' perspec- tive, using simple concepts such as change in main prob- lems or symptoms and well-being [3,4]. Furthermore, it is difficult to know from these measures how meaningful any reported changes are in terms of impact on the indi- viduals' daily life. The ORIDL (Outcome in Relation to Impact on Daily Liv- ing) instrument measures patients' views of the outcome of care [5]. Created initially for evaluating experimental clinics [6], its increasing adoption under its former name, the Glasgow Homoepathic Hospital Outcome Scale (GHHOS), in a number of centres [7-11] and studies [12- 17] has created a need to study its validity which has not previously been explored. It differs from many other scales by asking about change directly, and by relating outcome to the effect of the intervention on impact on daily life. In the present paper we report on a series of studies in which we have had the opportunity to compare the ORIDL with three validated measures in secondary (integrative care) and primary (conventional care) set- tings. Methods The rationale behind the development of the ORIDL was to base the instrument on the type of dialogue that the doctor (or other health care professional) and patient would have to evaluate outcome in the clinical encounter. For example, a dialogue may be as follows: Doctor: Well, was there any effect from what we did? Patient: Yes, I think it helped... Doctor: Yes, but was it a useful effect? Can you give me an example? Patient: Yes, it was really useful, I was able to get about more and go to the shops. Doctor: Really? And is that a major change, a really marked benefit, or is it less than that? Patient: No, this is really marked, it's the best thing I've had for the problem. I'm not saying It has cured it or any- thing, I mean I still have the problem, but I could live with it now. The aim was to embed the essence of these dialogues in the design of the instrument, but allow it to be standard- ised in a way that would allow a questionnaire based ver- sion of the scale to measure the participants' opinions on the effects of the intervention (not their view on the natu- ral progression of the health problems being considered). The validation studies took place in the outpatient unit of GHH, an NHS-funded Centre for Integrative care, and in primary conventional care in an area of high deprivation in Glasgow. Ethical approval was obtained for all 3 studies from the West of Glasgow University NHS Trust. Written consent was obtained from all patients. In the GHH study 1, four senior doctors took part and the participants were adult out-patients attending the GHH for various periods of time (see ref 12 for details). In GHH Study 2, nine doc- tors took part (not including 2 of the 4 senior doctors who took part in study 1) and the participants were all new outpatients above 12 years of age whom the doctors saw in the 3 months from September to December 2002, as reported previously [14]. In study 3, five GP Principals took part working in the same Practice, and the partici- pants were adult patients registered with the practice. The ORIDL offers nine options for the participant to choose. In study 1, the format used to elicit patients' views was as shown in Figure 1. In study 2, a different format was used to elicit patients' views on these 9 options, as shown in Figure 2. This ques- tion was then repeated for 'your overall well-being'. In study 3, the format used in study 1 was adopted (Figure 1), but modified to 'the overall effect of your treatment by your GP' as it was a primary care study of general practi- tioners. A score of 2 or above was used as a 'ORIDL threshold' score as the wording at this level records an effect on qual- ity of daily living as perceived by the patient. Choosing timings and targets The target and timing of use of the ORIDL is chosen by the participants and the context, and so reporting needs to make clear what choices were used. We have used ORIDL in the current studies for patients' views. It is less explored for recording practitioners own views. Presenting results Individual results can be recorded in the medical casenotes as need be, perhaps beside the intervention they refer to, or as overall results. This has been useful in clinical prac- tice at the GHH as a 'shorthand' code allowing the care team to share a sense of the value or otherwise of interven- tions. Group results can be presented graphically to show Page 2 of 10 (page number not for citation purposes) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 The following questions ask you, compared to how you were when you first attended GHH, what has been the overall effect of your treatment at Glasgow Homoeopathic Hospital on your main complaint, and general feeling of well-being with the problem up to the present time?” Please complete the 2 boxes using the scale shown above: 1.The main complaint for which you came for treatment 2. Your overall well-being +4 Cured /Back to normal +3 Major Improvement +2 Moderate improvement, affecting daily living +1 Slight improvement, no effect on daily living 0 No change/Unsure -1 Slight deterioration, no effect on daily living -2 Moderate deterioration, affecting daily living -3 Major deterioration -4 Disastrous deterioration FOiRguIDrLe f1ormat in study 1 ORIDL format in study 1. the range of results for a group or cohort of patients, as reported in the present paper. Procedure Immediately before their consultation, the patients were asked to complete the EQOL [18] (Study 1, GHH) or the SF-12 [18] (Study 2; GHH) and during the consultation (with the practitioner) they did the initial MYMOP [3] (Study 2; GHH, Study 3; Primary Care). After the consul- tation they completed demographic questions and put the forms in a sealed collection box. In Study 1, the patients were posted a follow up questionnaire containing the EuroQOL and ORIDL (main complaint and well-being) at 12 months after baseline assessment. In Study 2, the patients were posted follow up questionnaires at 3 months, 12 months and 33 months after initial consulta- tion (baseline assessment) containing the SF-12, MYMOP, and ORIDL. In Study 3, patients were posted a follow up questionnaire at 3–4 weeks after contact consul- tation (baseline assessment). In studies 1 and 2, non- responders received two postal reminders, in study 3, 1 postal reminder followed by a telephone call. Validated measures used to compare with ORIDL The Measure Yourself Medical Outcome Profile (MYMOP) has four items which are completed during the consultation [3]. The patients choose (with regard to their main problem) up to two main symptoms and one activ- ity of daily living, which are scored for severity over the past week on a seven-point scale (from 0 = "As good as it could be", to 6 = "As bad as it could be"). In a similar way a general well being question is completed. By adding up the scores to all the items and dividing the total by the number of answered items an overall profile score is cal- culated. On the follow up questionnaire the wording of the chosen symptoms and activity are copied and scored again by the patients [3]. The EuroQOL-5D (EQOL) and the Short Form 12 (SF-12) are both widely used self-completed instruments to meas- ure health status [18,19]. In the EQOL, five domains make up the descriptive system of the instrument; mobil- ity, self-care, usual activities, pain/discomfort, and anxi- ety/depression. There are three possible responses for each domain. Results can be presented descriptively, or scores added to give an un-weighted total score or an index (weighted) score can be calculated from published tables togiveaco-efficientbetweenzeroandone.Inaddition the EQOL has a VAS component which asks the patient to rate their current health status on a visual analogue scale from 0 (worst imaginable health state) to 100 (best imag- inable health status). Finally, the EQOL also includes a transition measure, asking patients to rate their current health state against the previous 12 months (Better, Same Worse). In the SF-12, twelve questions comprise several concepts, such as physical functioning, social functioning, and bodily pain. The responses are weighted and com- bined to derive two summary scales: (1) the physical com- ponent score (PCS), which is an indicator of physical health (2) the mental component score (MCS), which is an indicator of mental health. The two scores range Page 3 of 10 (page number not for citation purposes) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 The following questions ask you what the overall effect your treatment has had on your main complaints, general feeling of well-being, and your coping with the problem up to present time. The questions are asked in such a way that they reflect the dialogue you may have during the consultation with your doctor or practitioner. Please, answer the questions by ticking the boxes and then follow either the arrows to the next question or the instructions next to boxes. 1. Your main complaint(s)... (please tick boxes) 1. “Has the treatment caused any improvement or deterioration in your main complaint(s)?” +1 Yes, it improved 0 No, no change (Please go to Q.2) -1 Yes, it got worse 2................ “Is/was this change enough to affect the quality of your daily living?” +2 Yes, it improved No, no change (Please go to Q.2) -2 Yes, it got worse 3............................... “Is/was this change very marked, a major effect?” +3 Yes, a major improvement No, no change (Please go to Q.2) -3 Yes, a major deterioration 4. “Is/was this change a complete resolution or disastrous deterioration of the problem?” +4 Yes, a complete resolution No, neither -4 Yes, a disastrous deterioration FOiRguIDrLe f2ormat in study 2 ORIDL format in study 2. between 0 and 100 and higher scores imply better overall health. The Patient Enablement Instrument (PEI) is a six-item measure that was developed and validated to measure the immediate outcome of consultations in primary care [20]. However, we have recently used the PEI to measure patients views on enablement over time [14] and qualita- tive work suggests it may be a useful outcome for patients in terms of changes in self-concept [21]. Therefore we have reported on the PEI as a longer-term outcome meas- ure (PEI-Outcome) in the present paper. Participants Study 1 (GHH) – patients completed the follow-up study at 12 months, patient details have been reported else- where [12,22]. Study 2 (GHH) – patients completed the follow up ques- tionnaire at three months, at twelve months, and 33 months. Details of the patients characteristics have been previously reported [14]. An additional time points at 20 months was included using the ORIDL only. Study 3 (Primary Care) – patients completed the follow up questionnaire at 1 month. Analysis The data were analysed through the statistical package SPSS. Comparisons between the ORIDL scores with the change scores (i.e. the difference between the scores from the first and follow up questionnaires) of the EQOL, MYMOP and SF-12 was assessed by using Spearman's rank correlation coefficient. Through independent sam- ples t-tests it was checked whether people who had scores below the ORIDL threshold (< +2) had significantly lower change scores on the MYMOP and SF-12 than the people who had scores above the ORIDL threshold (+2 and above). Results Study 1: ORIDL and EQOL scores over 12 month 105 patients consented to follow-up, and 74 returned the questionnaire at 12 months (75% response rate). Of these 74, there were 5 missing values (6.8%) for ORIDL (both main complaint and well-being). Missing values for EQOL ranged from 6.8–10.9%, (mean 9.0%). Page 4 of 10 (page number not for citation purposes) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 Figure 3 shows the distribution of ORIDL scores at 12 months post contact consultation in patients attending the GHH. The majority of patients reported overall improvements in their main complaint and well-being, with some 68% and 77% reporting improvements in quality of daily living (ORIDL scores of 2+ or better) in main complaint and well-being, respectively. However, the lack of a 'ceiling effect' should also be noted, with no patient recording a score of plus 4 ('cured'). With the EQOL, small but statistically significant improvements (p < 0.001, chi-squred) between baseline and follow-up scores were observed for usual activities (13% of patients showing improvement), pain/discom- fort (22% showing improvement) and anxiety/depression (13% showing improvement). No significant changes were found in mobility or self-care (results not shown). A significant but small difference in EQOL VAS score was found between baseline and follow-up (baseline; mean Health State Today 62.5, follow-up: mean Health State Today 68.6, p = 0.001) signifying a small improvement in perceived overall health status. The EQOL transition score (Health state today compared with 12 months ago) showed much larger perceived changes, with 66% of patients reporting 'better', 21 % 'same' and 13% 'worse' health state. Table 1 shows the correlations between ORIDL and EQOL scores. No significant correlations were found between the ORIDL and the EQOL total score for the change in the 5 domains between baseline and follow-up (calculated as either a weighted or un-weighted total scores). Changes in the individual domains of the EQOL were also not signif- icantly correlated with the ORIDL, except for a weak cor- relation (rho 0.25, p = 0.04) between EQOL-Mobility and ORIDL-Well-Being (results not shown). EQOL-VAS change showed a weak but significant correlation with ORIDL-wellbeing score but not with ORIDL-main com- plaint (Table 1). However, EQOL-transitions score (per- ceived change over the last 12 months) were highly correlated with both components of the ORIDL (Table 1). Similarly PEI-Outcome scores (change in enablement over 12 months) were also significantly related to ORIDL scores (Table 1). The correlation between ORIDL-main complaint and ORIDL-well being was 0.724, p < 0.001. gFOoiRgwuIDHrLeosm3coreeospoatvheirc 1H2omspoitnatlh(sSitnudpyat1ie)nts attending the Glas- ORIDL scores over 12 months in patients attending the Glas- gow Homoeopathic Hospital (Study 1). Study 2: ORIDL and MYMOP and SF-12 scores at 3 months, 12 months, and 33 months in new patients 187 new patients consented to follow-up, and question- naire response rates were 117 (63%), 76 (41%) and 75 (40%) at 3, 12, and 33 months respectively. Missing val- ues for ORIDL items at the different time points ranged from 0.9 – 6.4% (mean 3.4%). Missing values for MYMOP symptom 1 and well-being items ranged from 40 30 20 10 0 -2.00 -1.00 .00 ORIDL-MC 1.00 2.00 3.00 17 33 35 6 4 4 50 40 30 20 10 0 3 41 36 9 6 6 -2.00 -1.00 .00 ORIDL-WB 1.00 2.00 3.00 Table 1: Spearman's correlations between ORIDL and EQOL at GHH (study 1) ORIDL-main complaint ORIDL-well being 0.083 (63) 0.029 (63) 0.261 (64) * 0.546 (67)*** 0.487 (67)*** Change in EQOL Score (un-weighted) Change in EQOL Score (Weighted) Change in EQOL – VAS EQOL – transition scale PEI Outcome * p < 0.05, ** p < 0.01, *** p < 0.001 0.201 (63) 0.115 (63) 0.152 (64) 0.643 *** (66) 0.418 ***(67) (page number not for citation purposes) Page 5 of 10 Percent Percent BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 5.3–15.8% (mean 11.0%) and for SF-12 items from 4.0– 22.4% (mean 13.6%). Figure 4 shows the ORIDL scores (expressed as % scoring 2+ or above) of new patients attending the GHH followed prospectively up to 33 months. As can be seen there was a slow but steady improvement in main complaint and well-being in terms of effect on daily life over the 33 month period. The baseline and follow-up scores at 3 months and 12 months for the SF-12 and the MYMOP have been pub- lished previously (Bikker et al 2005) and showed no changes in SF-12 scores but significant improvement in MYMOP scores. Similarly, SF-12 scores showed no signif- icant changes between baseline and 33 months for either the physical or mental health components (results not shown). MYMOP scores did however show significant improvements (paired t-test) in scores for symptoms (baseline 4.24, 33 months 3.16, p < 0.001), well-being (baseline 3.50, 33 months 2.84, p < 0.01), and profile score (baseline 4.02, 33 months 3.18, p < 0.001). Table 2 shows the correlations between ORIDL and MYMOP, SF-12 and PEI-outcome at 3,12, and 33 months. As can be seen, ORIDL scores were only weakly related to SF-12 change scores at all 3 time points, with few signifi- cant correlations. However, ORIDL and MYMOP change scores were much more highly correlated, showing signif- icant relationships to each other at all time points and for all components reported (MYMOP symptom change, MYMOP well-being change, and MYMOP profile change all significantly related to both ORIDL main complaint and ORIDL well-being). There was no indication that the strength of the correlation between ORIDL and MYMOP weakened with time (i.e., correlations at 33 months were as strong, if not stronger, than at 3 months). The strongest correlations with ORIDL was generally with the change in MYMOP profile score. IFmiogpnurtorhevse4amteGnHtsHin(dStauildyyliv2i)ng reported by the ORIDL over 33 Improvements in daily living reported by the ORIDL over 33 months at GHH (Study 2). Table 2 also shows that the PEI-outcome measure also correlated significantly with the ORIDL at 3 months and 12 months (PEI-outcome was not measured at 33 months). 50 40 30 20 10 44 24 37 20 3 months Time (months) 12 months 20 months 33 months 50 40 30 20 10 0 40 15 35 13 3 months Time (months) 12 months 20 months 33 months Table 2: Spearman's correlation between ORIDL and SF-12, MYMOP, and PEI at GHH (study 2) ORIDL – main complaint ORIDL – well being 12 months 0.152 (57) 0.040 (57) 0.487** *(62) 0.485*** (69) 0.439** *(63) 0.640*** (63) SF-12 PCS Change SF-12 MCS Change MYMOP Change inProfile MYMOP Change in Symptoms MYMOP Change in Well-Being PEI Overall Outcome 3 months 0.214* (90) 0.245* (90) 0.444*** (90) 0.433*** (109) 0.334** (102) 0.451** (105) 12 months 0.186 (56) 0.015 (56) 33 months 0.224 (63) 0.334** (63) 3 months 0.211* (90) 0.235* (90) 0.400** (99) 0.435** *(109) 0.333** (101) 0.528*** (104) 33 months 0.336** (63) 0.388** (63) 0.541*** (68) 0.446***(70) 0.383** (64) - Page 6 of 10 0.474*** (61) 0.444** *(68) 0.314* (62) 0.586***(62) - 0.499** *(68) 0.440 ** *(70) 0.390** (64) * p < 0.05, ** p < 0.01, *** p < 0.001 (page number not for citation purposes) ORIDL-WB Score +2 or above (%) ORIDL-MC Score +2 or above (%) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 Table 3: Spearman's correlation of ORIDL with MYMOP and PEI in primary care (study 3) 40 30 20 10 0 29 22 6 17 18 3 3 -2.00 -1.00 .00 ORIDL-main complaint 1.00 2.00 3.00 4.00 50 40 30 20 10 0 40 17 15 15 4 3 4 -3.00 -2.00 ORIDL-well being -1.00 .00 1.00 2.00 3.00 4.00 MYMOP Profile Score MYMOP Symptom 1 Score MYMOP Well-Being Score PEI Outcome *** p < 0.001 ORIDL- main complaint 0.510*** 0.553*** 0.358*** 0.572*** ORIDL- well being 0.437*** 0.409*** 0.385*** 0.584*** FOiRguIDrLe o5utcomes in primary care at 1 month ORIDL outcomes in primary care at 1 month. Study 3 (Primary Care): ORIDL and MYMOP at 1 month post-baseline 323 patients consented to follow-up, and 159 returned the questionnaire at 1 month (49% response rate). Of these 159, missing values (6.8%) for ORIDL main com- plaint and well-being items were 10% and 11%, respec- tively. Missing values for MYMOP symptom 1 and well- being items ranged from 2.0–7.0% (mean 4.7%). Missing values for PEI ranged from 2.6–5.0% (mean 4.0). Figure 5 shows the distribution of ORIDL scores 1 month after contact consultation in primary care. The percent reporting a significant impact of daily living for main complaint is 43% and for well-being is 34%. The percent- age reporting no change (a score of zero) was 29% for main complaint and 40% for well-being. This was similar to the percentage showing no change (a change score of zero) for the MYMOP (32% for symptom 1, 41% for well- being). For MYMOP scores at baseline and 1 month significant improvements were found in symptom (baseline 4.50, 1 month 3.58, p < 0.001) and profile score (baseline 4.07,1 month 3.64, p < 0.001) but not in well-being (baseline 3.53, 1 month 3.53). Table 3 shows the relationship between ORIDL and MYMOP and PEI in primary care. ORIDL components were highly and significantly correlated with all MYMOP change scores, with the highest correlations found between ORIDL -main complaint and MYMOP symptom change and profile change. A significant relationship between MYMOP well-being change and the ORIDL items was also found. PEI-outcome was highly correlated with the ORIDL items. The ORIDL threshold score (+2) Scores of ≥ +2 on the ORIDL denotes a meaningful change in the outcome to the patient (i.e. sufficient to improve daily living), so it was hypothesised that patients with scores of +2 and above would have significantly higher results on the change scores of the MYMOP compare with patients with ORIDL scores below +2. As Table 4 shows, this was the case in all instances in all three studies and at all time points measured. Discussion The development of the ORIDL instrument arose from directly asking patients questions of clinical relevance: 'Did the treatment work?', 'Was it any good?', 'Is this serv- ice helping reduce suffering?' Determining outcome is always challenging, 'proof' changes as it emerges from a complex of scientific, cultural and personal factors – an 'Evidence Mosaic' – determined as much by who is asking the question, why and when, as by any abstract notion of pure science [23]. The ORIDL scale contributes by being rooted in the patient's experience of how the outcome of care has affected their daily life. As the scale (under its former name of GHHOS) has come into use in clinical and research contexts in recent years by virtue of its high face validity and practical ease of use, this paper's aim was to formalise its introduction, comment on its practical use, and take forward issues of validity. Page 7 of 10 (page number not for citation purposes) Percent Percent BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 Table 4: Mean change in MYMOP profile scores in ORIDL categories 2+ or better versus less than 2+ n 73 GHH 12 mths Mean (SD, n) GHH 33 mths Mean (SD, n) GP 1 mth Mean (SD, n) 0.027 (1.47) 47 ORIDL-main complaint MYMOP Change (Profile) GHH (3 mths) Mean (SD) < 2+ 0.00 (1.38) 2+ or better 1.49 (1.17) 26 1.61 (0.98) 14 ORIDL-well being < 2+ 2+ or better 0.14 1.09 (1.48) (1.24) 73 26 0.38 1.58 (1.51) (0.536) 53 9 p-value <0.01 <0.05 <0.01 <0.001 P-value <0.001 <0.01 0.15 (1.49) 3236 4028 0.25 1.31 (1.26) (1.42) 106 37 <0.001 0.31 0.99 (1.36) (1.32) 114 28 1.40 (1.27) <0.001 0.32 1.48 (1.46) (1.29) In the present series of studies, the ORIDL instrument showed significant and moderate-high correlations with the MYMOP at all time-points examined and in both the secondary (integrative) care setting of the GHH (Study 2) and in the primary (conventional) care setting (Study 3). This is an important finding, given that the MYMOP is now a well established instrument used to chart changes in patients symptoms and well-being, and is known to be to be more responsive to change than other widely-used tools such as the SF-36 [3] and the EuroQOL [23]. Fur- thermore, the consistency of the relationship between the ORIDL and the MYMOP, even up to 33 months after ini- tial baseline measurement, suggest a stability to the changes captured by the ORIDL. This is again of consider- able importance, given that academic opinion is divided on the use of transition measures versus serial measures when measuring health outcome. Whereas some argue that measuring change retrospectively (as in ORIDL) is highly fallible because it depends on accurate memory of the past [24,25], others take the opposite view, with evi- dence to show that patients' retrospective assessments are more sensitive, and correlate better with patient satisfac- tion and physical and biological indicators of change in disease state [26,27]. These two opposing academic views of psychometrics and 'clinimetrics' have not been recon- ciled as yet, and it has been argued that both may be valid and important depending on the context [20,26]. The ORIDL scale was created by a clinician (DR) and thus reflects this direct approach of asking patients about change, as carried out by clinicians in practice. However, by anchoring the scale in the concept of improvement in daily living, it may be that the ORIDL has a meaning not found in other transition scales. There was, as we expected, less correlation between the ORIDL and the EQOL, and the SF12, similar to the weak relationship shown between the EQOL and the MYMOP [28] and the SF-36 and the MYMOP [2], reflecting the pre- viously reported poor sensitivity to change by these two widely used tools. The significant correlations found between the EQOL transition scale and the ORIDL, and the PEI-outcome instrument and the ORIDL are new find- ings, not reported previously in the literature, though the use of the PEI as an outcome measure has been reported previously [14,21]. The response rate in the present series of studies varied, with a high response rate in study one (75%), but a diminishing response rate in study two (from 60–40%) and a 49% response rate in study three. However, we have no evidence to suggest the lower response rates were related to the ORIDL. It may well relate to the length of questionnaire and the context of the study. For example, study 3 was set in a primary care centre in an area of high socio-economic deprivation, where low response rates to postal follow-up is common (S Mercer, unpublished data). The fact that the number of missing items for ORIDL was low in all three studies, and around the same or less than the other instruments (MYMOP, EQOL, SF- 12), would support the face validity of the tool. However, qualitative work with patients is required to confirm this. Qualitative work is also required to allow us to establish the best way of presenting the ORIDL choices to patients. In the present work study 2 used a different format from the other two studies (as shown in the methods) but we have no information at present as to which format patients find easiest to understand. Page 8 of 10 (page number not for citation purposes) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 The current data should only be seen as part of a wider pic- ture of validation. Previous studies have found clinically coherent correlations between indicators of consultation quality and outcomes measured by ORIDL [10-12,20]. In terms of its clinical potential, any measurement scale can only give a simplified version of what goes on and cannot hope to capture and represent the richness and complexity of daily clinical care. However, as a contribution to patient-centred outcome measures, ORIDL has two key characteristics. Firstly, it is modelled on how patients and doctors already assess care in daily practice (i.e., by asking about change directly), and secondly, it anchors the out- come to the patient's assessment of significant deteriora- tion or improvement in terms of daily living. Further work is required to establish how many patients are needed per doctor in order to establish a reliable ORIDL score for individual doctors [25], if a comparison between doctors is desired. Further qualitative research is also required to assess patients' views on the ORIDL and this will be of major importance in trying to validate the instrument further. Strengths and weaknesses of the ORIDL Overall, we feel the scale has the following strengths: 1. It is quick and simple to use and its results are easy to communicate. 2. It is generic and so flexibly adaptive to different contexts and targets. 3. It aims to link outcome to the experience of daily living. 1. It is a broad-brush measure (and so lacks detail and pre- cision) and would often need supplemented by other measures if more detailed results are needed. 2. It is subjective, even though anchored in experience of daily living. 3. It is only as good as the participants' views, and shares all the strengths and weaknesses of ordinary clinical prac- tice. 4. It focuses only on the participants' views of the impact of the care – other issues like 'How?', or 'Duration?, or 'Why – e.g: placebo?', or, objective verification – need to be addressed through other approaches. 5. It can be used without a measured baseline, so is subject to the bias of recall, and the shift in perception as health status changes. Conclusion Given the current search for appropriate outcome meas- ures of routine care [29,30] we think it is worthwhile to try to relate measures of outcome to the patients' view of its impact on their daily lives. Clearly further work is required to validate the accuracy of the ORIDL in assess- ing such change. However, our experience and data to date suggest that the ORIDL scale may prove of value in tracking routine care in clinical practice and in evaluating healthcare interventions. Competing interests The author(s) declare that they have no competing inter- ests. 4. It models how patients and practitioners already asses care in daily busy practice. 5. It can be used in routine clinical practice without dis- rupting the care process. 6. It may allow comparison across different contexts of healthcare in the degree of useful impact achieved by the intervention. 7. It establishes a useful shared language, for example, whatever the context if you say a patient experienced '+2' then others know that this was change was at least suffi- cient to impact on the quality of daily living. 8. It can be used without measuring a previous baseline, capturing the participants' views of any change over time. Some of its weaknesses are: Authors' contributions DR devised the ORIDL and co-supervised the research in studies 1 and 2. He wrote the initial version of the manu- script and contributed to modifications. He contributed in addition intellectual input at all stages. SWM carried out the data collection and analysis in Studies 1 and 3, and re-analysed part of the data in Study 2. He re-shaped the initial version of the manuscript, and led the re-writ- ing of subsequent versions. He also contributed intellec- tual input at all stages. APB carried out part of the data collection in Study 2, and analysed part of the data, and contributed to writing and modifying drafts of the manu- script. She contributed intellectually, especially to the interpretation of the data. TH carried out part of the data collection in Study 2, and contributed to the final version of the manuscript. All authors read and approved the final manuscript. Page 9 of 10 (page number not for citation purposes) BMC Health Services Research 2007, 7:139 http://www.biomedcentral.com/1472-6963/7/139 Acknowledgements Stewart Mercer is supported by a Primary Care Research Career Award from the Chief Scientist Office of the Scottish Executive. The AdHom Aca- demic Departments are supported by the AdHominem Charity. References 1. Swage T: Clinical governance in health care practice. Butter- worth Heinemann 2004. ISBN0750644532 2. Gill TM, Feinstein AR: A critical appraisal of the quality of qual- ity-of-life measurements. JAMA 1994, 272:619-626. 3. Paterson C: Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996, 312:1016-1020. 4. Paterson C: In pursuit of patient-centred outcomes: a qualita- tive evaluation of the 'Measure Yourself Medical Outcome Profile'. J Health Service Res Pol 2002, 5:27-36. 5. The Academic Departments of the Centre forIntegrative Care [http://www.adhom.com] 6. Reilly D, Taylor MA: Experimental integrated clinics. Comp Ther Med 1993, 1(Supplement 1):16-17. 7. Sevar R: Audit of outcome in 455 consecutive patients treated with homeopathic medicines. Homeopathy 2005, 94:215-21. 8. Neville-Smith R: Community hospital clinic: Audit of the first 12 months activity. Brit Hom J 1999, 88:20-23. 9. Sevar R: Audit of outcome in 829 consecutive patients treated with homeopathic medicine. Brit Hom J 2000, 89:178-187. 10. Richardson WR: Patient benefit survey: Liverpool regional department of homoeopathic medicine. Brit Hom J 2001, 90:158-162. 11. Riley D, et al.: Homeopathy and conventional medicine: An outcomes study comparing effectiveness in a primary care setting. J Alt Comp Med 2001, 7:149-159. 12. Mercer S, Reilly D, Watt G: The importance of empathy in the enablement of patients attending the Glasgow Homoeo- pathic Hospital. BJGP 2002, 52:901-905. 13. MacPherson H, Mercer SW, Scullion T, Thomas KJ: Empathy, ena- blement, and outcome: an exploratory study on acupunc- ture patients' perceptions. J Alt Comp Med 2003, 9:869-76. 14. Bikker AP, Mercer SW, Reilly D: A pilot prospective study on the consultation and relational empathy, patient enablement, and health changes over 12 months in patients going to the Glasgow Homoeopathic Hospital. J Alt Comp Med 2005, 11:591-600. 15. Greenwood JE: The challenge to find a safe and effective cure for verruca pedis. Podiatry Now 2004, 8:20-24. 16. Thompson EA, Montgomery A, Douglas D, Reilly D: A pilot, rand- omized, double-blinded, placebo-controlled trial of individu- alized homeopathy for symptoms of estrogen withdrawal in breast-cancer survivors. J Alt Comp Med 2005, 11(1):13-20. 17. Ricciotti F, Bernardini C, D'Aco L, Giannuzzi AL, Passali GC, Passali D: Pilot study on chronic rhinosinusitis in order to evaluate efficacy and tolerability of a standard antibiotic treatment (Amoxicillin and Clavulanic Acid) associated to an homeo- pathic complex (Dr. Reckeweg R1). Rivista Italiana di Otorinolarin- gologia Audiologia e Foniatria 2005, 25:109-117. 18. The EuroQol Group: EuroQol – a new facility for the measure- ment of health related quality of life. Health Policy 1990, 16:199-208. 19. Ware J, Kosinski M, Keller SD: A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of relia- bility and validity. Medical Care 1996, 34:220-233. 20. Howie J, Heaney DJ, Maxwell M, Walker JJ: A Comparison of a Patient Enablement Instrument (PEI) against two estab- lished satisfaction scales as an outcome measure of primary care consultations. Fam Pract 1997, 15:165-171. 21. Paterson C: Measuring change in self-concept: a qualitative evaluation of outcome questionnaires in people having acu- puncture for their chronic health problems. BMC Comp Alt Med 2006, 6:7. doi: 10.1186/1472-6682-6-7 22. Mercer SW: Practitioner empathy, patient enablement, and health outcomes of patients attending the Glasgow Homoe- opathic Hospital : a retrospective and prospective compari- son. Wien Med Wochenschr 2005, 155:498-501. 23. Reilly D, Taylor M: The Evidence Profile. Developing Inte- grated Medicine. Comp Ther Med 1993, 1:11-12. 24. Paterson C, Langan CE, McKaig GA, Anderson PM, Maclaine GDH, Rose LB, et al.: Assessing patient outcomes in acute exacerba- tions of chronic bronchitis: The measure your medical out- come profile (MYMOP), medical outcomes study 6-item general health survey (MOS-6A) and EuroQol (EQ-5D). Qual Life Res 2000, 9:521-527. 25. Guyatt GH, Norman GR, Jumiper EF, Griffith LE: A critical look at transition ratings. J Clin Epidemiol 2002, 55:900-908. 26. Steiner DL, Norman GR: Health measurement scales 3rd edition. Oxford: Oxford University Press; 2003. 27. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H: Capturing the patient's view of change as a clinical outcome measure. JAMA 1999, 282:1157-1162. 28. Ziebland S, Fitzpatrick R, Jenkinson C, Mowat A, Mowat A: Compar- ison of two approaches to measuring change in health status in rheumatoid arthritis: the Health Assessment Question- naire (HAQ) and modified HAQ. Ann Rheum Dis 1992, 51:1202-1205. 29. Paterson C: Seeking the patient's perspective: a qualitative assessment of EuroQol, COOP-WONCA Charts and MYMOP. QualLife Res 2004, 13:871-881. 30. Verhoef MJ, Vanderheyden LC, Dryden T, Mallory D, Ware M: Eval- uating complementary and alternative medicine interven- tions: in search of appropriate patient-centred outcome measures. BMC Comp Alt Med 2006, 6:38. doi:10.1186/1472-6882- 6-38 Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1472-6963/7/139/pre pub Publish with Bio Med Central and ever y scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: BioMedcentral http://www.biomedcentral.com/info/publishing_adv.asp (page number not for citation purposes) Page 10 of 10 

Principles of Epidemiology (for CBC Marketplace)

http://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf

Why extreme dilutions reach non-zero asymptotes: a nanoparticulate hypothesis based on froth flotation.

http://www.ncbi.nlm.nih.gov/pubmed/23083226 Langmuir. 2012 Nov 13;28(45):15864-75. doi: 10.1021/la303477s. Epub 2012 Nov 1. Why extreme dilutions reach non-zero asymptotes: a nanoparticulate hypothesis based on froth flotation. Chikramane PS1, Kalita D, Suresh AK, Kane SG, Bellare JR. Author information Abstract

Extreme dilutions, especially homeopathic remedies of 30c, 200c, and higher potencies, are prepared by a process of serial dilution of 1:100 per step. As a result, dilution factors of 10(60), 10(400), or even greater are achieved. Therefore, both the presence of any active ingredient and the therapeutic efficacy of these medicines have been contentious because the existence of even traces of the starting raw materials in them is inconceivable. However, physicochemical studies of these solutions have unequivocally established the presence of the starting raw materials in nanoparticulate form even in these extreme (super-Avogadro, >10(23)) dilutions. In this article, we propose and validate a hypothesis to explain how nanoparticles are retained even at such enormous dilution levels. We show that once the bulk concentration is below a threshold level of a few nanograms/milliliter (ng/mL), at the end of each dilution step, all of the nanoparticles levitate to the surface and are accommodated as a monolayer at the top. This dominant population at the air-liquid interface is preserved and carried to the subsequent step, thereby forming an asymptotic concentration. Thus, all dilutions are only apparent and not real in terms of the concentrations of the starting raw materials.

Homeopathic treatment of multimorbid patients: a prospective outcome study with polarity analysis

Homeopathic treatment of multimorbid patients: a prospective outcome study with polarity analysisHeiner Freiemail University of Berne, Kreuzplatz 6, CH-3177 Laupen, Switzerland Received: March 13, 2014; Received in revised form: August 27, 2014; Accepted: September 2, 2014; Published Online: October 10, 2014 DOI: http://dx.doi.org/10.1016/j.homp.2014.09.001 Publication stage: In Press Corrected Proof

Abstract Full Text Images References

Highlights

•We examined the treatment outcome with polarity analysis in 50 multimorbid patients. •43 patients were successfully treated and reached an average improvement of 91%. •The cost of homeopathic treatment is estimated to be 41% of a conventional therapy. •Thus, homeopathy can play a substantial role in treating multimorbid patients.

Background

The treatment of multimorbid patients who have a combination of three or more concurrent complaints is one of the core competencies of homeopathy. In this article we introduce the application of polarity analysis (PA) in multimorbidity. PA came to prominence through the Swiss homeopathic ADHD double-blind study, which successfully demonstrated a significant difference between highly dilute homeopathic remedies and placebo. PA enables homeopaths to calculate a relative healing probability, based on Boenninghausen's grading of polar symptoms. After its evaluation in the treatment of a variety of acute and chronic disease, which showed improved results compared to a conventional homeopathic approach, it was a challenge to test PA with multimorbid patients. Since such patients almost invariably have a multiple symptoms, the question was whether we can nevertheless successfully use Polarity Analysis or whether the method is rendered ineffective by the multitude of symptoms. Methods

We treated 50 multimorbid patients with PA and prospectively followed them over one year. Results

43 patients (86%) completed the observation period, achieving an average improvement of 91% in their initial symptoms. Six patients dropped out, and one did not achieve an improvement of 80%, and was therefore also counted as a treatment failure. The cost of homeopathic treatment was 41% of projected equivalent conventional treatment. Conclusions

Polarity Analysis is an effective method for treating multimorbidity. The multitude of symptoms does not prevent the method from achieving good results. Homeopathy may be capable of taking over a considerable proportion of the treatment of multimorbid patients, at lower costs than conventional medicine. http://www.homeopathyjournal.net/article/S1475-4916%2814%2900084-8/abstract

Will CBC bring more attention to Homeoprophylaxis (what they’ll describe as an alternative to vaccines) than homeopaths can?!?

http://www.newagora.ca/will-cbc-bring-more-attention-to-homeoprophylaxis/ Will CBC bring more attention to Homeoprophylaxis (what they’ll describe as an alternative to vaccines) than homeopaths can?!?

A few years ago, a journalist requested information on homeopathy for a show on CBC. I am a typical Canadian and so therefore I have a strong affinity for CBC.

I asked the organizers of the show whether this would be a fair and true representation of homeopathy. I know that it is easy to target aspects of homeopathy because of its complex and unique principles of healing. However, the producers of CBC’s Marketplace expressed specifically and clearly that this would not be the way they would use the information they gather. I met with them and they interviewed me at my clinic. I also faithfully gave them a number for one of my clients that had agreed she wouldn’t mind being interviewed. I printed out for them a thick pile of many research reports that presented sound science backing up many of the principles of healing used in the science of homeopathy. That show which has repeated more times than any other episode of CBC’s Marketplace ended up being truly blatantly biased and absolutely NOT scientific. There was no mention of the scientific reports that I and others had given to them.

When that episode was shown, there were many people who posted words of support and commitment to the option of homeopathy in the healing choices. The Marketplace website seemed to edit and only release a certain number of the responses. People writing in support of homeopathy reported that their posts had not been published. People wrote in to CBC’s producers, CBC’s Ombudsman, and the homeopathic community bonded over the outrage of this slander. This fall, CBC plans to release another show about an aspect of homeopathic practice known as homeoprophylaxis. Homeoprophylaxis is the use of homeopathic remedies in anticipation for prevention of a specific health concern. The founder of homeopathy, Samuel Hahnemann writes about using the principles of homeoprophylaxis back in 1798 in his publication on Scarlet Fever called “The Cure and Prevention of Scarlet Fever”, in ‘Lesser Writings’ (B.Jain Publishing. New Delhi. P.369ff). http://www.feg.unesp.br/~ojs/index.php/ijhdr/article/viewFile/360/407 using the homoeopathic remedy called Belladonna. He also refers to the ways to conduct homeoprophylaxis in the Aphorisms number 100, 101, 102 and 241 of his written guide to homeopathy known as ‘The Organon’ first published in 1810 (Hahnemann S. Organon of medicine. 6th Edn. (Translated by William Boericke). New Delhi: B Jain Publishers, 1991). The most contemporary uses of homeoprophylaxis are based on the science conducted mostly by Dr. Isaac Golden http://www.homstudy.net/Research/

and Dr. G. Bracho. http://www.ncbi.nlm.nih.gov/pubmed/20674839

Despite that currently there exists (and will continually be more of) quality research to demonstrate the effective use of homeopathy to address specific health concerns, CBC will attempt to convince you that there is none. Let me guide you to the BOX WIDGET on my blog https://homeopathiccures.wordpress.com

That is where you’ll be able to access homeopathic expert’s advice or writings by homeopathic experts. In the words of Merriam-Webster Dictionary (http://www.merriam-webster.com/dictionary/expert), an expert is defined as “having or showing special skill or knowledge because of what you have been taught or what you have experienced”. With this in mind, please QUESTION who CBC will refer to as ‘experts’ on topics of homeopathy.

Instead of truthfully facing the experts on homeopathy (myself and a known few of my colleagues) CBC Marketplace’s approach to get information from us was to plant a fake client into our private practice. A few months later, an email was sent to me stating that they had done this and would I do an interview them?

Instead they chose a mysterious random bunch of people https://homeopathiccures.files.wordpress.com/2014/09/centre-for-inquiry.pdf…random people who don’t know that you can NOT overdose on homeopathic remedies – and that this is a GOOD thing BUT that it is IRRESPONSIBLE to try to do your own ‘experiments’ on a form of medicine that you don’t have a clue about.

Needless to say, I am NOT doing any kind of happy dance http://animalfactoftheday.blogspot.ca/2012/04/manakin-bird-can-moonwalk.html in anticipation of a new episode focusing on Homeoprophylaxis.

The tragic irony is that I have a feeling that CBC Marketplace’s blatant show of ignorance will be apparent to most critical thinkers that are their audience and those people will either look for more information to satisfy their curiosity OR they will stand stronger in their commitment to choices for health care options for Canadians. In case this is the place you’ve come to for more information, let me assure you that maintaining the homeopathy as a choice made available to us is more important than our regular freedoms of choice as it has to do with the most important aspect of our existence because as they say, ‘if we don’t have our health, what do we have?’ That is the essence of what drives most people to homeopathy. In ONE country alone there are over 100 million people using homeopathy (http://drnancymalik.wordpress.com/article/status-of-homeopathy/)(India). Also keep in mind that the top two most debated topics on Wikipedia are Jesus and homeopathy If you’ve seen the CBC Marketplace’s representation of homeopathy and would like to take part in some discussions about it, please keep in touch at https://www.facebook.com/AccessNaturalHealing/photos/a.119846306893.123640.10145471893/10152470442151894/?type=1&theater

Sincerely Yours in Homeopathy Elena Cecchetto (EL) info@accessnaturalhealing.com 604-568-4663 http://www.accessnaturalhealing.com © 2014 Elena Cecchetto

A model for homeopathic remedy effects: low dose nanoparticles, allostatic cross-adaptation, and time-dependent sensitization in a complex adaptive system.

BellKoithan2012BMCCAMNanoparticleModelHomeopathyFINAL1472-6882-12-191.pdf http://www.ncbi.nlm.nih.gov/pubmed/?term=2012+BMCCAM+Nanoparticle+Model+Homeopathy+FINAL+1472-6882-12-191.pdf A model for homeopathic remedy effects: low dose nanoparticles, allostatic cross-adaptation, and time-dependent sensitization in a complex adaptive system. Bell IR1, Koithan M. Author information Abstract BACKGROUND:

This paper proposes a novel model for homeopathic remedy action on living systems. Research indicates that homeopathic remedies (a) contain measurable source and silica nanoparticles heterogeneously dispersed in colloidal solution; (b) act by modulating biological function of the allostatic stress response network (c) evoke biphasic actions on living systems via organism-dependent adaptive and endogenously amplified effects; (d) improve systemic resilience. DISCUSSION:

The proposed active components of homeopathic remedies are nanoparticles of source substance in water-based colloidal solution, not bulk-form drugs. Nanoparticles have unique biological and physico-chemical properties, including increased catalytic reactivity, protein and DNA adsorption, bioavailability, dose-sparing, electromagnetic, and quantum effects different from bulk-form materials. Trituration and/or liquid succussions during classical remedy preparation create "top-down" nanostructures. Plants can biosynthesize remedy-templated silica nanostructures. Nanoparticles stimulate hormesis, a beneficial low-dose adaptive response. Homeopathic remedies prescribed in low doses spaced intermittently over time act as biological signals that stimulate the organism's allostatic biological stress response network, evoking nonlinear modulatory, self-organizing change. Potential mechanisms include time-dependent sensitization (TDS), a type of adaptive plasticity/metaplasticity involving progressive amplification of host responses, which reverse direction and oscillate at physiological limits. To mobilize hormesis and TDS, the remedy must be appraised as a salient, but low level, novel threat, stressor, or homeostatic disruption for the whole organism. Silica nanoparticles adsorb remedy source and amplify effects. Properly-timed remedy dosing elicits disease-primed compensatory reversal in direction of maladaptive dynamics of the allostatic network, thus promoting resilience and recovery from disease. SUMMARY:

Homeopathic remedies are proposed as source nanoparticles that mobilize hormesis and time-dependent sensitization via non-pharmacological effects on specific biological adaptive and amplification mechanisms. The nanoparticle nature of remedies would distinguish them from conventional bulk drugs in structure, morphology, and functional properties. Outcomes would depend upon the ability of the organism to respond to the remedy as a novel stressor or heterotypic biological threat, initiating reversals of cumulative, cross-adapted biological maladaptations underlying disease in the allostatic stress response network. Systemic resilience would improve. This model provides a foundation for theory-driven research on the role of nanomaterials in living systems, mechanisms of homeopathic remedy actions and translational uses in nanomedicine.

Effectiveness of homoeopathic therapeutics in the management of childhood autism disorder

http://www.ijrh.org Indian Journal of Research in Homoeopathy / Vol. 8 / Issue 3 / Jul-Sep 2014 147 ORIGINAL ARTICLE Effectiveness of homoeopathic therapeutics in the management of childhood autism disorder Praful M. Barvalia, Piyush M. Oza, Amit H. Daftary, Vijaya S. Patil, Vinita S. Agarwal 1 , Ashish R. Mehta 2 ABSTRACT Background and Objectives: Childhood autism is severe and a serious disorder. A study was conducted by Spandan holistic institute of applied Homoeopathy, Mumbai, with the objective of demonstrating the usefulness of homeopathic management in autism. Materials and Methods: Sixty autistic children of both sexes, ≤12 years were selected for this study. It was nonrandomized, self‑controlled, pre and post‑intervention study, wherein the initial 6 months of observation period was used as the control period and the same patients were thereafter treated for 1 year and compared with post‑intervention findings. Results: The study demonstrated significant improvement of autistic features with mean change in ATEC score (ATEC 1 ‑pre‑treatment with ATEC 5 ‑post‑treatment) was 15.12 and ATEC mean percent change was 19.03. Statistically significant changes in ATEC scores were observed in all the quarters analyzed through repeated measures ANOVA, with F‑ value 135.952, P = 0.0001. An impact was observed on all core autistic features, which included communication, 12.61%, socialization, 17%, sensory awareness, 18.82%, and health and behavior, 29% ( P = 0.0001). Significant improvement was observed in behavior by Autistic Hyperactivity Scale, AHS 1 36 to AHS 5 14.30 with F‑value 210.599 ( P = 0.0001). Outcome assessment was carried out using MANOVA, which showed statistically significant changes in post‑treatment scores, P < 0.005. Total 88.34% cases showed improvement, 8.33% showed status quo, and 3.33% cases worsened. Nine out of 60 cases showed a reversal of CARS putting them into non‑autistic zone, P = 0.0001. A sharp decrease (34%) in ATEC scores, in the first quarter implied positive effect of homoeopathic medicines, prescribed, as per the homoeopathic principles. Conclusion: The study has demonstrated usefulness of homoeopathic treatment in management of neuropsychological dysfunction in childhood autism disorder, which is reflected in significant reduction of hyperactivity, behavioral dysfunction, sensory impairment as well as communication difficulty. This was demonstrated well in psychosocial adaptation of autistic children

Homeoprophylaxis aka "Alternative to Vaccines or Homeopathic Vaccines" as CBC Marketplace would describe it as!

Dearest Clients,
Sometime this year I received a call from a young mother expressing concerns about
the safety of vaccines for her baby and asking if she and another woman (I forget
what she said their relation was) could come in and talk to me about homeopathic
alternatives (CBC's fake client). This is a common request from (especially
educated) parents, aware of media stories of vaccine damage as well as the myopic
perspective of mainstream medicine for whom there are no alternatives, no
accommodations, no individualizing of vaccination schedules. For this, I offer a
"Free Information Session" until they decide to come in for the First Consultation
appointment so that they know I will not be offering any therapeutic advice during
this information session.
People who come to talk to me about vaccination concerns and seeking information
about alternatives are presented with a nuanced discussion. I cannot ignore the
plethora of requests for information and I believe it is against my code of ethics
as a health practitioner (See ethics on Beneficence vs. NonMaleficence) to not offer
the information which I am an expert on (homeopathy). I end these discussions with
the advice that the parents go home, think, read, research, talk, and then let me
know the ways that I can best support their child’s health and wellbeing, no matter
what decision they make in the end: full vaccination, no vaccination, partial
vaccination.
This was exactly the sort of conversation I had with CBC's fake client. The fake was
not actually a concerned mother, but a reporter for CBC Marketplace who came into my
clinic (with maybe a fake baby and friend) under false pretenses, and then proceeded
to clandestinely tape and film our meeting for the purpose of “undercover”
journalism in preparation for an upcoming episode on CBC Marketplace on vaccination
alternatives. The ethical issues involved in this approach are extraordinary, and I
think it important that all Canadians know the sordid activities of their public
broadcaster. The extraordinary thing is that the CBC’s own regulations on
clandestine reporting suggest that it is allowed only in situations in which there
is “antisocial” behavior, “abuse of trust”, or there is no other way to get the
information needed. I am not sure which of these descriptors cover the visit to my
office, but certainly, the homeopathic community has been fully forthcoming in
offering Marketplace information on homeoprophylaxis without any secret high jinx
involved.
For some of my clients, the bully tactics of my patient-in-disguise did not end
there. Upon leaving, “the fake” asked for a nosode remedy to protect her baby
against measles while she and her husband were making their decision about
vaccination; she told them they would be travelling to an area where there had
recently been a measles outbreak and they were concerned about exposure. Of course
they helped her – this is what homeopaths do. It turns out that Marketplace then
made a formal complaint to Health Canada about the labeling of the remedy(ies) that
had dispensed (the ONLY complaints made to Health Canada regarding homeopathic
treatments ever made as far as I know). Unfortunately, “the fake” and their team
didn’t do their research and were unaware of the regulations that cover homeopathic
practitioners. Needless to say, Health Canada found the complaints spurious and
dismissed them, assuring the homeopaths that they were practicing well within
regulatory norms. I might add, that Health Canada has conferred a DIN-HM number on
many nosodes plus over 6000 different remedies, giving them a “seal of approval” as
it were. There is no salacious story here, no matter how Marketplace frames it.
So it turns out that the Marketplace episode on vaccines will be aired tonight on
CBC. If you watch the program, please know the producers have a strong bias against
homeopathy -- and are likely to present homeopaths as luring parents away from
vaccination. The illicitly filmed segments of myself and the other homeopaths
similarly witch-hunted are most assuredly small excerpts of much more complex
conversations, taken out of context and presented without any of the other
information offered.
Perhaps this offers a good opportunity for people to speak up for homeopathy and to
speak up for free choice in making decisions about the health decisions we make. If
you are invested in the vaccine issue you can go online to CBC Marketplace's site
(www.cbc.ca/marketplace ) for the episode entitled "Vaccines: Shot of Confusion" and
post about your experiences, and share your decision making process around this
issue. It is important that homeopaths do not allow themselves to be pushed into the
closet because of the bully pulpit of media shows such as CBC Marketplace. Speak up
– let them know what you think.
If you would like any other resources to refer to, please feel free to refer to
http://www.homeopathiccures.wordpress.com
for research and other publications on homoepathy and homeoprophylaxis from around
the world.

Nonlinear Response Amplification Mechanisms for Low Doses of Natural Product Nanomedicines: Dynamical Interactions with the Recipient Complex Adaptive System

Belletal2013NonlinearAmplificationMechanismsforHomeopathicNanomedicines.pdfwww.omicsonline.org

Nonlinear Response Amplification Mechanisms for Low Doses of Natural Product Nanomedicines: Dynamical Interactions with the Recipient Complex Adaptive System Iris R Bell1,2, Barbara Sarter3, Mary Koithan2, Leanna J Standish4, Prasanta Banerji5 and Pratip Banerji5

1Department of Family and Community Medicine, The University of Arizona College of Medicine, USA 2College of Nursing, The University of Arizona, Tucson, AZ, USA 3Hahn School of Nursing and Health Sciences, University of San Diego, San Diego, California, USA 4Bastyr University, Kenmore, WA, USA 5PBH Research Foundation, Kolkata, India Abstract The purpose of the present paper is (a) to outline the self-organized, complex adaptive network nature of the organism as recipient of nanomedicines; (b) to propose several nonlinear endogenous amplification processes by which pulsed low doses of traditional, homeopathically-manufactured natural product nanomedicines may stimulate a return toward healthier function; and (c) to discuss their potential relevance to novel, but safer than conventional dosing strategies for contemporary nanomedicines. Homeopathy is an over 200-year-old system of complementary and alternative medicine (CAM) that uses low doses of natural plant-, mineral-, and animal-sourced nanomedicines. Homeopathic manufacturing is “green”, with mechanical grinding in lactose and agitation in ethanol-water as primary reagents. Agitation within glass containers at room temperature may also contribute nanosilica and nanosilicon as drug delivery vehicles and biological amplifiers. The medicine selection is matched to the recipient organism’s systemic patterns of dysfunction and pulsed in the timing of the discrete doses. Endogenous amplification processes within the recipient organism may involve hormesis, time-dependent sensitization, and/or stochastic resonance. Effects are adaptive and systemically diffuse, i.e., causally indirect, rather than pharmacological and local, i.e., direct. All of these nonlinear response processes require interaction of the nanoparticle (NP) dose with the organism as a complex adaptive system. The pulsed NP dose serves as a low intensity salient danger signal for the organism to make network-wide adaptive changes that can lead to healing. The historically safe therapeutic approach of homeopathic nanomedicine dosing avoids risks of high, continuous doses and cumulative toxicity that contemporary nanomedicine researchers are now trying to solve while using NPs as if they were conventional bulk drugs. Integrating the insights, technical procedures, and clinical dosing approaches from modern and homeopathic nanomedicine could lead to major advances in the field for more effective and safer translational applications. Keywords: Nanomedicine; Homeopathy; Nanoparticles; Hormesis; Stochastic resonance; Nonlinear dynamical systems; Complex adaptive systems.

Extreme homeopathic dilutions retain starting materials- A nanoparticulate perspective

Extreme homeopathic dilutions retain starting materials- A nanoparticulate perspective Extreme homeopathic dilutions retain starting materials: A nanoparticulate perspective Prashant Satish Chikramane1, Akkihebbal K Suresh1,2, Jayesh Ramesh Bellare1,2,* and Shantaram Govind Kane1,* 1Department of Chemical Engineering, Indian Institute of Technology (IIT), Bombay, Adi Shankaracharya Marg, Powai, Mumbai 400 076, Maharashtra, India 2Department of Biosciences and Bioengineering, Indian Institute of Technology (IIT), Bombay, Adi Shankaracharya Marg, Powai, Mumbai 400 076, Maharashtra, India Homeopathy is controversial because medicines in high potencies such as 30c and 200c involve huge dilution factors (1060 and 10400 respectively) which are many orders of magnitude greater than Avogadro’s number, so that theoretically there should be no measurable remnants of the starting materials. No hypothesis which predicts the retention of properties of starting materials has been proposed nor has any physical entity been shown to exist in these high potency medicines. Using market samples of metal- derived medicines from reputable manufacturers, we have demonstrated for the first time by Transmission Electron Microscopy (TEM), electron diffraction and chemical analysis by Inductively Coupled Plasma-Atomic Emission Spectroscopy (ICP-AES), the presence of physical entities in these extreme dilutions, in the form of nanoparticles of the starting metals and their aggregates. Homeopathy (2010) 99, 231e242. Keywords: Homeopathy; Nanoparticles; Nanocrystalline materials; Transmission Electron Microscopy Introduction Homeopathy, a mode of therapy, was established in the late 18th century by German physician, Samuel Hahne- mann. Hahnemann, during his experiments, prepared medi- cines from a wide variety of natural products. He discerned that the infinite dilutions of these substances carried out in steps and accompanied by vigorous shaking ‘succussion’ (together known as potentization) at each dilution step, elicited some kind of a potent activity to these solutions.1,2 In spite of the various controversies and frequent challenges by the scientific community regarding its efficacy, this mode of treatment has stood the test of time, and is still being used in many countries for treatment of various chronic conditions, with medicines being prepared from a variety of herbal, animal, metal and other mineral sources. *Correspondence: Jayesh Ramesh Bellare and Shantaram Go- vind Kane, Department of Chemical Engineering, Indian Institute of Technology (IIT), Bombay, Adi Shankaracharya Marg, Powai, Mumbai 400 076, Maharashtra, India. E-mail: jb@iitb.ac.in, sgkane@gmail.com Received 6 November 2009; revised 22 April 2010; accepted 22 May 2010 However, a major lacuna has been the lack of evidence of physical existence of the starting material. The main dif- ficulty in arriving at a rational explanation stems from the fact that homeopathic medicines are used in extreme dilu- tions, including dilution factors exceeding Avogadro’s number by several orders of magnitude, in which one would not expect any measurable remnant of the starting material to be present. In clinical practice, homeopathic potencies of 30c and 200c having dilution factors of 1060 and 10400 respectively, far beyond Avogadro’s number of 6.023 1023 molecules in one mole, are routinely used. Many hypotheses have been postulated to justify and elu- cidate their mechanisms of action. While some hypotheses such as the theory of water memory,3e5 formation of clathrates,6 and epitaxy7 are conjectural in nature, others such as those based on the quantum physical aspects of the solutions8,9 have not been sufficiently tested, either due to complexity in validating the hypothesis or due to non-reproducible results. The ‘silica hypothesis’10 is the only model that proposes the presence of physical entities such as siloxanes or silicates resulting from leaching from the glass containers. Following a dearth of credible and test- able hypotheses to identify any physical entity responsible for medicinal activity, most modern scientists continue to believe that homeopathy at best provides a placebo effect. Homeopathy (2010) 99, 231e242 ! 2010 The Faculty of Homeopathy doi:10.1016/j.homp.2010.05.006, available online at http://www.sciencedirect.com ORIGINAL PAPER  232 Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Despite the extreme dilutions in 30c and 200c potencies, our approach has been to test for the presence of the starting materials in the form of nanoparticles.. Medicines selected were metal-based, and were so chosen that the metals would not arise either as impurities or as contaminants. The six metals and their respective homeopathic medicines were gold (Aurum metallicum or Aurum met), copper (Cuprum metallicum or Cuprum met), tin (Stannum metallicum or Stannum met), zinc (Zincum metallicum or Zincum met), silver (Argentum metallicum or Argentum met) and platinum (Platinum metallicum or Platinum met). Three potencies: 6c, 30c, and 200c were selected. The dilution factor for 6c is 1012 which is less than Avogadro’s number, whereas the dilution factors for 30c and 200c are well above. Market samples of these medicines in 90%v/v ethanol were obtained from two reputable manufacturers: SBL, India, and Dr. Willmar Schwabe India (WSI) Private Limited. We examined the following physico-chemical aspects: a. The presence of the physical entities in nanoparticle form and their size by Transmission Electron Microscopy (TEM) by bright-field and dark-field imaging. b.Their identification by matching the Selected Area Electron Diffraction (SAED) patterns against literature standards for the corresponding known crystals. c. Estimation of the levels of starting metals by a 500-fold concentration of medicines, followed by chemical analysis using Inductively Coupled Plasma-Atomic Emission Spectroscopy (ICP-AES). Materials and methods Materials The homeopathic medications used for the purpose of re- search were obtained commercially from authorized distrib- utors of a leading homeopathic drug manufacturer in India (SBL) and an Indian subsidiary of a multi-national homeo- pathic company viz. Dr. Willmar Schwabe India Pvt. Ltd. Random batch number samples were purchased from the market and no special effort was made to get samples from the company. Since we purchased these medicines from the market, only in certain cases were we able to obtain them from a single manufacturing batch. Also no special ef- forts were made to obtain the drugs from a batch. The High- performance liquid chromatography (HPLC) grade ethanol used for the purpose of ICP-AES analyses was procured from Commercial Alcohols Inc., Canada. The TEM grids obtained from Pacific Grid-Tech (USA) were 200 mesh cop- per grids coated with carboneformvar. Methods then allowed to dry completely after which another drop was added. The usual drying time for each drop was ap- proximately 30e60 min in air at room temperature. This procedure was repeated 5 times. After air-drying the sam- ple for further 30e60 min, the grid was kept under an IR lamp for approximately 20 min to ensure complete drying of the sample and thereby preventing the possibility of solvent molecules from adhering to the particles on the grid. The SAED patterns of the particles were taken and the d-spacings were calculated using the camera length (calibrated daily using a standard gold colloid). The dark-field images were also taken by selecting three spots from two inner rings on the SAED pattern. The d-spacing values from SAED patterns and the crystallite sizes from the dark-field images were calculated using the Image-J software. Elemental composition by ICP-AES: The determination of the starting elements in ultra-trace concentrations was performed on Ultima 2, (Jobin Yvon Horiba, Japan). The operating parameters for the ICP-AES instrument were as follows: plasma gas flow rate (Argon gas): 12 l/min; auxil- iary gas flow rate: 0.2 l/min; sample uptake: 2.5 ml/min; integration time: 5.0 s, Spray Chamber: cyclonic chamber. The limit of detection of the instrument was 10 ppb. For the purpose of ICP-AES analyses, the samples were pre- pared by pre-concentrating the solutions (6c, 30c, and 200c potencies) 500-fold in a vacuum rotary evaporator, Roteva Model #8706R (Equitron, India) at 45C and 100 rpm speed. The homeopathic medicines that we purchased were in ei- ther 100 ml or 500 ml capacity bottles. Most of the SBL homeopathic medicine bottles were of 500 ml capacity with a few of 100 ml capacity, while those obtained from Willmar Schwabe India (WSI) Pvt. Ltd. were all 100 ml bot- tles. In the case of medicines obtained as 500 ml bottles, so- lutions from 4 bottles of the same medicine and potency were pooled together for concentration, whereas for medi- cines which were marketed as 100 ml bottles, solutions from 20 bottles of each medicine at the same potency were pooled. The concentration was carried out in a 50 ml clean round bottom flask on a rotary vacuum evaporator. The flask was filled with the solution (approximately 30e35 ml at a time) and the solvent was evaporated. Upon complete evaporation of the solvent, the flask was re- filled with fresh homeopathic solution and the process was repeated till the entire volume of 2000 ml was evaporated. Only one bottle was opened at a time to maintain the integ- rity of the purchased medicines. To prevent contamination, under no circumstances was the solution in the bottle kept exposed. The residues of Cuprum met, Stannum met, and Zincum met were acidified to solubilize the particles of their respective starting metals by addition of concentrated nitric acid. Similarly, aqua regia (concentrated nitric acid and con- centrated hydrochloric acid in the ratio 1:3) was added to residues of Aurum met, Argentum met, and Platinum met. A 1:1 ratio of water: acid was maintained for all the concen- trated samples. The amount of acid and water was adjusted so that the final volume was 4 ml, thus, amounting to a con- centration by a factor of 500. The samples were filtered Nanoparticle characterization by TEM/SAED: analyses were performed on Tecnai G2 120 kV Cryo-TEM (FEI, Hillsboro, USA). All samples were viewed at 120 kV. The TEM analyses were performed for the medicines by placing a drop of the original solution (without pre-concen- tration) on the carboneformvar coated copper TEM grids in a clean environment. The drop of the solution was The TEM Homeopathy through Whatman 40 filter paper to remove the residual mat- ter prior to analysis. The SBL samples were analyzed in trip- licate and samples from WSI were analyzed in duplicate. As a negative control, 90%v/v ethanol samples were also pre- pared using HPLC grade ethanol and Milli-Q water. These ethanolic solutions were also concentrated in the manner similar to that employed for the medicines. The emission lines selected for measuring the concentra- tion of the metals are as follows: Gold: 242.795 nm, Copper: 324.754 nm, Tin: 283.999 nm, Zinc: 213.856 nm, Silver: 328.068 nm, Platinum: 265.945 nm. The instrument re- sponse was calibrated using standards prior to analyses of the samples. Results and discussion Determination of size and morphology by TEM Zincum met, Aurum met, Stannum met and Cuprum met 30c and 200c were analyzed by TEM. The results are given as photomicrographs (Figure 1(a)e(p)), which clearly dem- onstrate the presence of nanoparticles and their aggregates. Due to extreme dilution often only a single nanoparticle or a large aggregate is seen. Hereafter, the term ‘particles’ col- lectively refers to the nanoparticles and their aggregates. We noted a high polydispersity of the particles in the so- lutions with respect to their shapes and sizes for various medicines and potencies. A scrupulous examination of the entire manufacturing process of these medicines sug- gested that two key processes played a vital role in impart- ing the high polydispersity. They are: 1. The dilution steps in the solid phase (till 6 potency) in- volved trituration of the raw materials with lactose. Such a comminution process is expected to generate particles of varied shapes and sizes. The physical characteristics of these particles are dependent on the type of raw mate- rial and the shearing force applied. 2. During liquid dilutions, the succussion process at each potentization step played a vital role. The succussions given to the liquid mass are expected to produce particles of varied shapes and sizes due to three factors including shearing forces generated during the pounding of the liq- uid container against an elastic stop, the properties of the raw materials involved, and variations during pounding of the container, between individuals. The permutations and combinations of the above-men- tioned factors and the possible subtle differences in the manufacturing processes employed by various manufac- turers can explain the findings regarding polydispersity between different medicines and manufacturers. We also made another prominent observation regarding the presence of surface asperities on the particles which were clearly evident from the differences in contrast on sur- faces of these particles along with a substantial difference in their size between different starting metals. Thus, larger aggregates were found in Zincum met (Figure 1(a)e(d)) and Stannum met (Figure 1(i)e(l)) as compared to those Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al observed in Aurum met (Figure 1(e)e(h)) and Cuprum met (Figure 1(m)e(p)) at the same potencies. The mechanism of cavitation or generation of vapor bub- bles caused by ultra-sound irradiation (acoustic cavitation) in the entire liquid mass during manufacturing may explain the observations noted above. We suggest that the process of succussion is the cause of cavitation. As set out in a later section, the extant theories of cavitation11e14 can, in principle, provide an explanation of our findings. The aggregation behavior of the particles seems to be de- pendent on the physical property of the starting metal, spe- cifically its melting point. We observed that the aggregates of zinc in Zincum met and tin in Stannum met were rela- tively larger as compared to the smaller aggregates of gold and copper found in Aurum met and Cuprum met re- spectively. The bulk melting points of tin and zinc are w505 K and w692 K respectively as compared to the higher melting points of gold and copper (w1337 K and w1357 K respectively). A decrease in melting points of metallic and semiconductor particles with decreasing size has also been well characterized.15 A combination of ex- tremely high surface temperatures along with a decrease in the melting point of these particles could facilitate the formation of aggregates that we found. It is probable that during the succussion process, the col- lisions of the particles induce surface temperatures well above the melting points of tin and zinc, thereby facilitat- ing their aggregation. However, the melting points of gold and copper being much higher, the occurrence of melting and fusion of these particles would be relatively less frequent than for tin and zinc. Overall, our data for bright-field TEM do not indicate a major difference in the size or nature of the particles in a particular medicine as we increase potency from 30c to 200c. Therefore, the individual crystallite sizes were deter- mined by dark-field TEM (as shown for Zincum met for both manufacturers in Figure 2(a)e(d)). We observed that the aggregates of all the metals tested had maximum crystal- lites (w40e50%) in the size range of 5e10 nm, and that 70e95% of all the crystallites were below 15 nm (Figure S1 e Supplementary information). Thus, in the case of dark-field TEM also, there was no major potency- dependent difference in size distribution of crystallites. Confirmation of elemental composition of particles by SAED The nanoparticles and aggregates identified in TEM were analyzed by SAED for confirmation of the elemental compo- sition. We took multiple SAED patterns of the same particle at varying intensities so as to focus on the inner and outer rings for calculation of the d-spacings of the respective ele- ments. The SAED patterns of the nanoparticles and their ag- gregates found in the metal-based homeopathic medicines are represented in Figure 3(a)e(p). SAED analyses of all samples showed patterns consis- tent with the starting materials. In particular, Aurum met and Cuprum met from both suppliers (SBL and WSI) in- dexed to gold and copper respectively. Table 1 shows the values of the d-spacings calculated from the diameters of 233 Homeopathy 234 Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Figure 1 Bright-field TEM images of nanoparticles and aggregates. Zincum met: (a) 30c (SBL), (b) 200c (SBL), (c) 30c (WSI), (d) 200c (WSI). Aurum met: (e) 30c (SBL), (f) 200c (SBL), (g) 30c (WSI), (h) 200c (WSI). Stannum met: (i) 30c (SBL), (j) 200c (SBL), (k) 30c (WSI), (l) 200c (WSI). Cuprum met: (m) 30c (SBL), (n) 200c (SBL), (o) 30c (WSI), (p) 200c (WSI). the ring patterns of particles observed in Aurum met sam- ples. Similarly, in the case of Stannum met from SBL, the observed pattern indexed to a-Sn whereas that from WSI to b-Sn. In the case of Zincum met samples from both sup- pliers, we did not observe pure metallic zinc, but the SAED patterns indexed to zinc hydroxide which is an expected compound derived from zinc (d-spacing data for zinc, tin and copper have been given as Supplementary information e Tables S2eS5). The confirmed presence of these crystalline species of starting materials or those derived from them (as evident from the SAED patterns) despite the ultra-high dilutions Homeopathy such as 30c and 200c was astounding, proving that the starting materials were retained even with extremely high dilutions. The d-spacing values for the particular elements con- formed well to the Joint Committee on Powder Diffraction Standards (JCPDS) data in literature in the range of `2%. However, for some d-spacings corresponding to a few planes in the crystal, the values differed by approximately `4%. The differences in some of the d-spacing values for each metal can be explained on the basis of induction of mi- nor plastic deformations in the crystals. The initial tritura- tion process involving high shearing forces, together with the succussion process involving high-velocity collisions of nanoparticles resulting in the generation of shock waves caused by the imploding cavitations, may have induced minor plastic deformations in the metal crystals. In a few of the SAED patterns for the metals analyzed, the particles also showed presence of diffused ring Figure 1 (continued). Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al 235 Homeopathy 236 Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Figure 2 Bright-field and corresponding dark-field TEM images of nanoparticles and aggregates observed in Zincum met: (a) 30c (SBL), (b) 200c (SBL), (c) 30c (WSI), (d) 200c (WSI). Inset e SAED patterns of the corresponding nanoparticle/aggregate. patterns similar to that of an amorphous material. The probable reason for presence of amorphous phases on the surface of the nanoparticles and aggregates is de- scribed later in this paper. On the whole, the SAED data indicated that the particles of the starting materials were present in the homeopathic medicines even in po- tencies such as 30c and 200c. In order to quantify the ex- act amounts of these starting metals in ultra-high potencies, we conducted the ICP-AES analyses of these medicines. Estimation of concentration of the starting materials by ICP-AES ICP-AES is an established technique for the estimation of metals and other elements. Our equipment had a mini- mum detectable limit of 10 ppb, thereby necessitating Homeopathy Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Figure 3 SAED patterns of corresponding nanoparticles and aggregates (shown in Figure 1(a)e(p)). Zincum met: (a) 30c (SBL), (b) 200c (SBL), (c) 30c (WSI), (d) 200c (WSI). Aurum met: (e) 30c (SBL), (f) 200c (SBL), (g) 30c (WSI), (h) 200c (WSI). Stannum met: (i) 30c (SBL), (j) 200c (SBL), (k) 30c (WSI), (l) 200c (WSI). Cuprum met: (m) 30c (SBL), (n) 200c (SBL), (o) 30c (WSI), (p) 200c (WSI). 237 Homeopathy Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al 238 Figure 3 (continued). Homeopathy PS Chikramane et al Table 1 Electron diffraction pattern e comparison of d-spacing for Aurum met 30c and 200c potencies 239 Nanoparticles of starting materials in homeopathic medicines hkl values Relative intensity 111 100 200 52 220 32 311 36 222 12 400 6 331 23 420 22 422 23 333 e 440 e 531 e 442 e 620 e 533 e 622 e 444 e d-spacing Gold [#A] 2.3550 2.0390 1.4420 1.2300 1.1774 1.0196 0.9358 0.9120 0.8325 0.7850 0.7210 0.6890 0.6800 0.6450 0.6220 0.6150 0.5890 Aurum met 30C SBL e Figure 3(e) 2.0300 1.2000 1.0700 0.7600 0.6600 Aurum met 200C SBL e Figure 3(f) 2.0393 1.4389 1.2598 1.1809 1.0072 0.9120 0.7843 0.7179 0.6939 Aurum met 30C WSI e Figure 3(g) 2.3515 2.0213 1.4454 1.1732 1.0152 0.9079 0.8286 0.7196 Aurum met 200C WSI e Figure 3(h) 2.3312 2.0224 1.4418 1.2514 1.1695 1.0211 0.9530 All d-spacing values are in #A units. d-spacing data in ‘bold’ e from JCPDS#04-0784, remaining d-spacing data from Edington.16 concentration of the homeopathic solutions using a tech- nique in which there is absolutely no possibility of adding inadvertently the metal to be detected. The analyses of the metal-based medicines, performed after the concentration of the solutions gave startling re- sults. The starting metals were detected for all potencies (6c, 30c, and 200c) at concentrations of the order of picogram/ml (pg/ml). The measured concentrations are presented in Table 2. The data presented in the table are back-calculated concentrations of the metals in the origi- nal homeopathic medicines. The analyses of the negative control of 90%v/v ethanol did not indicate the presence of either the noble metals or tin, and for metals such as cop- per and zinc, indicated far lower concentrations than those in the medicines. We analyzed several samples of Aurum met, Argentum met, and Platinum met for the presence of their respective starting metals. In the case of Aurum met (SBL), some of the samples tested, including higher potencies such as 30c and 200c indi- cated presence of approximately 60e100 pg/ml of gold; the levels being much higher than the sensitivity of the instrument whereas in the ethanolewater negative controls there was no signal for the presence of gold. However, a few Aurum met (SBL) samples did not show presence of gold. Our results point towards a considerable batch-to-batch variation in the concentrations of the starting material. This is certainly not surprising, considering that the method of preparation in- volved manual processes along with an absence of any at- tempt to estimate the concentrations of the starting materials at the end of the manufacturing process of a partic- ular batch. The Aurum met (WSI) samples did not show gold in detectable quantities. Analogous results were obtained for the Argentum met (SBL) samples wherein silver was detected in one 30c and one 200c sample (30.6 pg/ml and 116 pg/ml respec- tively). The concentrations in the other samples were below the detection limit. Likewise, we discerned detect- able concentration of platinum (w40e220 pg/ml) in the Platinum met (SBL) samples for all potencies. The concentrations of non-noble metals such as copper, tin and zinc in their respective homeopathic medicines viz. Cuprum met, Stannum met, and Zincum met were higher (2e30 times that of noble metals) and easily detectable. In the Cuprum met samples (SBL), we detected w500e2500 pg/ml of copper in the solutions. Similarly, 6c potency of WSI indicated high concentration of copper (w370 and w900 pg/ml respectively in the two samples). However, the concentrations of copper in the higher poten- cies viz. 30c and 200c were very low (w10e40 pg/ml) in some and below detectable limits in the others. Likewise for Stannum met samples (SBL) we detected tin; albeit with very high variations from w70 to 1000 pg/ml. In the WSI homeopathic solutions of Stannum met however, lower concentrations of tin were detected in the range of w20e180 pg/ml. As compared to the other samples of non-noble metals noted above, the concentration of zinc in the Zincum met samples was much higher. In the Zincum met samples we detected presence of zinc with a very high variation in the concentrations between manufacturers from w200 to 2700 pg/ml and w1400 to 4000 pg/ml for SBL and WSI respectively. It was reassuring that there was good reproducibility in terms of the estimated concentrations of the starting mate- rials in the pair of samples of the same medicine, potency, and the manufacturing batch. We observed a variation up to 40% in the samples prepared from the same manufacturing batch as compared to a variation up to 1550% in samples from different batches. These results clearly highlighted the following: 1. Validation of the accuracy of our method involving pre- concentration of the medicines prior to analyses as exemplified by the moderate variation in intra-batch samples (refer data sets for Cuprum met, Stannum met, and Zincum met marked in bold in Table 2). 2. High inter-batch variation in the concentration of the starting materials for a given manufacturer and potency, and between manufacturers. Homeopathy 240 PS Chikramane et al Table 2 Estimated concentration of starting metals in various potencies by ICP-AES (pg/ml) Homeopathic dilution SBL (pg/ml) WSI (pg/ml) 12312 Nanoparticles of starting materials in homeopathic medicines 90%v/v Ethanol ND Aurum met 6c 81.4 Aurum met 30c 64.8* Aurum met 200c ND 90%v/v Ethanol 153.4 Cuprum met 6c 1199.0 Cuprum met 30c 730.2 Cuprum met 200c 485.4 90%v/v Ethanol ND Stannum met 6c 569.4 Stannum met 30c 901.6 Stannum met 200c 877.8 90%v/v Ethanol 208.2 Zincum met 6c 380.0 Zincum met 30c 655.2 Zincum met 200c 357.8 90%v/v Ethanol ND Argentum met 6c ND Argentum met 30c ND Argentum met 200c ND 90%v/v Ethanol ND Platinum met 6c 220.6* Platinum met 30c 41.0* Platinum met 200c 213.6 ND 76.4 ND 104.6 245.0 995.2 703.2 432.2 ND 409.2 889.6 1055.8 210.2 366.0 165.4 191.2* ND ND 116.0 ND ND ND 58.2 ND 149.0 1355.6* 1383.4* 2680.2* ND 195.8* 145.6 63.8* 199.0 1002.8 1224.0 2743.6 ND 30.6 ND ND Samples not obtained ND ND Samples not obtained ND ND ND ND 245.0 149.0 893.4 370.8 38.6* ND ND ND ND ND 180.8 153.0 93.8 76.4 20.8 73.0 208.2 210.2 1432.6* 3989.6 3068.6* 1377.6 2230.2* 2322.8 Samples not obtained Samples not obtained ‘Bold’ against a pair of samples in Limit of Detection (LOD) of the instrument was 10 ng/ml corresponding to 20 pg/ml in the original solutions. All concentrations below this value have been reported as ‘Not Detected’ or ‘ND’. * Data indicate that the bottles used to make up the required quantity (2000 ml) were from the same manufacturing batch. Thus, for each metal-based medicine of a particular po- tency, the estimated values appeared to be within a band of 2 orders of magnitude. These variations could be attributed to the processes employed for manufacturing. A visit to a reputed manufacturer revealed that the initial lactose trit- urations were performed on an automated machine using a mortar and pestle. Apart from the control of particle sizes of the metal powders at 1 potency (wherein 80% of the particles of the starting material should be below 10 mm and none above 50 mm),17 there are no further checks for the distribution of the metals in the triturated 6 mixture, which is the starting material for proceeding to the liquid based succussion steps. This is believed to be the cause of these large variations. The liquid dilutions and the potentization steps (includ- ing succussion) were done manually during manufactur- ing, wherein the entire mass of the liquid in the glass container was pounded against a rubber stop 10 times, with inevitable variation in the force of impact and the ex- tent of cavitation generated during these human powered succussions. Apart from the initial trituration with lactose, succussion per se could also be an important method of generation of nanoparticles of the starting materials, due to intense shearing of these nanoparticles against the walls of the glass containers, by the fluid shear and possibly by particle collision due to the implosion of the cavitations created by the ultra-sound waves generated. Therefore, a difference in the shearing force imparted during succus- sion could result in a large difference in the formation of the nanoparticle fraction of the starting materials, thereby reflecting as inter-batch variation. Once the succussion process was completed, the entire mass of liquid was allowed to settle, prior to transfer of 1% of this dilution to 99 parts fresh 90%v/v ethanol. How- ever, the settling time for the dilutions was not fixed. Also, the removal of one part of the previous dilution for the pur- pose of transferring into a fresh solvent was carried out ran- domly from the container and was a manual process. All the above-mentioned factors combined are expected to im- part a lot of disparity in the concentrations of the starting materials in the final medicines which we observed in our studies. During our analyses we also noted the plateauing effect of the concentrations of the starting metals per se in a partic- ular concentration range in potencies 6c, 30c and 200c, in spite of 30c and 200c potencies being 1048 and 10388 respec- tively more dilute than 6c. It is interesting to note that the plateau for non-noble metals showed a higher metal content than for noble metals. Our ICP-AES results suggested that the asymptote effect commences around 6c potency (Figure 4). Our findings appear to be an extension of the trends noted at lower potencies by Ro ̈der et al.,18 who analyzed the concentrations of a few metals in decimal dilutions from 6 to 8 (corresponding to centesimal potencies of 3c to 4c). Part ‘A’ in Figure 4 explicitly depicts de- crease in the concentrations of starting materials with di- lutions. Only in the case of Au3+ in AuCl3 solutions, the a row for given manufacturer and potency indicates their preparation from same manufacturing batch. The Homeopathy Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Figure 4 Estimated concentrations of starting elements in homeopathic potencies. Part ‘A’ e estimated by Ro ̈ der et al.18 e solid symbols: expected concentrations, open: estimated concentrations, circles: Au3+, star: Fe3+, left triangle: Hg2+, right triangle: Zn2+. Part ‘B’ e estimated by ICP-AES in our work e squares: zinc concentrations, open: Zincum met (SBL), solid: Zincum met (WSI), open triangles: gold concentrations in Aurum met (SBL) samples. The dotted line at 20 pg/ml indicates the LOD of the instrument. 241 actual concentrations determined were lesser than the expected concentrations (circles, solid: expected; open: estimated concentrations). On the contrary, the concentra- tions of Fe3+ though slightly lower than expected at the 6 potency, did not decrease as expected, and were in fact slightly higher at 7 and 8 potencies (stars, solid: expected; open: determined concentrations). Likewise, the concentrations of Hg2+ and Zn2+ were almost 200% higher than expected at 8 potency. A scrupulous, concurrent analysis of these results suggested the com- mencement of an asymptote formation in the vicinity of the 8 (i.e. 4c) potency. When the data from Part ‘A’ of the graph are compared with our data (Part ‘B’), there appears to be a plateauing effect, reached at 6c potency. While a plateau is reached for each metal, the concentra- tion range varied from one metal to another and between manufacturers. The plateau of Zincum met (WSI) (solid squares) was appreciably higher (between 1300 and 4000pg/ml) than that for Zincum met (SBL) (open squares), albeit with the inherent variation mentioned ear- lier. Similar trends were also observed for all the other metals that were analyzed. Possible key mechanisms at large dilutions Acoustic cavitation, a well studied phenomenon11e14 may explain our TEM findings regarding surface asperities and particle aggregation. Researchers have observed that the vapor bubbles generated due to the high-energy sound waves had temperatures exceeding a few thousand degrees (w5000 K) along with intense pressures (w1000 atm). The bubbles so formed had very short lives before imploding, creating intense shock waves which propel particles in the solution at extremely high velocities resulting in collisions which induced the following morphological changes on the particle surfaces: 1. When the particles collided head-on, localized melting occurred on their surfaces at the point of contact, with the temperatures being w3000 K. With the surrounding liquid at ambient temperature, the melted surfaces instantly cooled at extremely high rates (>1010 K/s), thereby solidifying the melted area instantaneously and fusing the particles at the point of contact to form aggregates. 2. The extremely high rate of cooling, while not allowing for re-crystallization at the point of contact, led to an amorphous phase on the particle surface as evident from the diffused rings obtained in the electron diffraction (ED) patterns. 3. Collision of particles at a glancing angle led to fragmen- tation of the particle surface which may have given rise to surface asperities. The above theories support our observations regarding the presence of the surface asperities we see in TEM, since the forceful pounding of the glass containers during the succus- sion process may have been instrumental in generating the ultra-sound waves, resulting in their formation. Homeopathy 242 Nanoparticles of starting materials in homeopathic medicines PS Chikramane et al Another question that arises from our observations is how in spite of such huge dilutions the particles of the start- ing materials are retained even at 200c potency? The an- swer to this question could lie in the manufacturing process itself. We perceive that during the succussion pro- cess, the pounding of solutions against a rubber stop gener- ates numerous nanobubbles19 as a result of entrapment of air and cavitation due to generation of ultra-sound waves. The particles of the starting material instantaneously get adsorbed on the surface of these bubbles and cavitations. This phenomenon could be similar to the mechanism of formation of Pickering emulsions,20e22 wherein the emulsified phase viz. air bubbles or liquid droplets are stabilized by a layer of particles. This nanoparticleenanobubble complex rises to the sur- face and can be within a monolayer once the total metal concentrations are well below 1ppm (Table S6 e Supplementary information). It is this 1% of the top layer of the solution which is collected and added to the next vessel, into 99 parts of fresh solvent and the succussion process is repeated. This transfer of the top 1% layer in each step will ensure that once we reach below a certain concentration i.e. well within a monolayer, the entire start- ing material continues to go from one dilution to the next, resulting in an asymptote beyond 6c. Conclusion Using state-of-the-art techniques (TEM, SAED, and ICP-AES) we have demonstrated the presence of nanopar- ticles of the starting materials and their aggregates even at extremely high dilutions. The confirmed presence of nano- particles challenges current thinking about the role of dilu- tion in homeopathic medicines. We have found that the concentrations reach a plateau at the 6c potency and be- yond. Further, we have shown that despite large differences in the degree of dilution from 6c to 200c (1012 to 10400), there were no major differences in the nature of the parti- cles (shape and size) of the starting material and their abso- lute concentrations (in pg/ml). How this translates into change in biological activity with increasing potency needs further study. Concrete evi- dence of the presence of particles as found by us could help take the research in homeopathy a step forward in under- standing these potentised medicines and also help to posi- tively change the perception of the scientific community towards this mode of treatment. Conflict of interest There are neither any financial nor any personal conflicts of interest with respect to the work carried out for this article. Acknowledgements We thank the Department of Earth Sciences and the Cryo-TEM central facility at IIT Bombay for ICP-AES and TEM analyses respectively. We also gratefully acknowledge funding by Shridhar Shukla, S G Kane and Industrial Research and Consultancy Center (IRCC), IIT Bombay. We also thank P N Varma for valuable insights. Supplementary data Supplementary data associated with this article can be found in the online version at doi:10.1016/j.homp.2010. 05.006. References 1 Khuda-Bukhsh AR. Laboratory research in homeopathy: Pro. 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